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  • Are You Experiencing: (Nakakaranas Ka Ba NG:) : Signature: - Date

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    chen morada
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    This document contains a health check form for visitors and clients. It collects information such as name, contact number, address, and temperature. It then asks a series of yes or no questions regarding current health symptoms like sore throat, body pains, or fever. It also asks if the individual has been in contact with a confirmed COVID-19 case, someone exhibiting symptoms, or if they have traveled outside of their home area recently. The individual signs to authorize the collection of this health data for controlling the spread of COVID-19 infection while acknowledging their privacy rights.

    Original Description:

    Original Title

    Health-Declaration-Form1

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    This document contains a health check form for visitors and clients. It collects information such as name, contact number, address, and temperature. It then asks a series of yes or no questions regarding current health symptoms like sore throat, body pains, or fever. It also asks if the individual has been in contact with a confirmed COVID-19 case, someone exhibiting symptoms, or if they have traveled outside of their home area recently. The individual signs to authorize the collection of this health data for controlling the spread of COVID-19 infection while acknowledging their privacy rights.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views1 page

    Are You Experiencing: (Nakakaranas Ka Ba NG:) : Signature: - Date

    Uploaded by

    chen morada
    This document contains a health check form for visitors and clients. It collects information such as name, contact number, address, and temperature. It then asks a series of yes or no questions regarding current health symptoms like sore throat, body pains, or fever. It also asks if the individual has been in contact with a confirmed COVID-19 case, someone exhibiting symptoms, or if they have traveled outside of their home area recently. The individual signs to authorize the collection of this health data for controlling the spread of COVID-19 infection while acknowledging their privacy rights.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Visitor/Client’s Health Check Form

    Temp:

    Name: __________________________ Contact No: ________________


    Address: _______________________________________________________

    HEALTH CONDITION CHECK


    1. Are you experiencing: YES NO
    (nakakaranas ka ba A. Sore Throat (Pananakit ng lalamunan/ Masakit
    ng:) lumunok)
    B. Body Pains (Pananakit ng Katawan)
    C. Headache (Pananakit ng Ulo)
    D. Fever for the past few days (Lagnat sa nakalipas na
    mga araw)
    2. Have you ever worked together or stayed the same close environment of a confirmed
    COVID-19 case? (May nakasama ka ba o nakatrabahong tao na kunpirmadong may COVID-
    19 / may impeksyon ng coronavirus?)
    3. Have you had any contact with anyone with fever, cough, colds and sore throat in the
    past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo sipon o sakit ng lalamunan
    sa nakalipas na dalawang (2) linggo?
    4. Have you ever travelled to any in NCR aside from your home? (Ikaw ba ay nagpunta sa
    iba pang parte ng NCR o Metro Manila bukod sa iyong bahay? Specify (Sabihin kung
    saan):____________________________________________
    I hereby authorize ELEMENTARY SCHOOL, to collect and process the data indicated herein for the purpose of effecting control of
    the COVID-19 infection. I understand that my personal information is protected by RA 10173. Data Privacy Act of 2012. and that I
    am required by RA 11469, Bayanihan to Heal as One Act. to provide truthful information.
    Signature: ________________________ Date: _______________

    Visitor/Client’s Health Check Form

    Temp:

    Name: __________________________ Contact No: ________________


    Address: _______________________________________________________

    HEALTH CONDITION CHECK


    1. Are you experiencing: YES NO
    (nakakaranas ka ba A. Sore Throat (Pananakit ng lalamunan/ Masakit
    ng:) lumunok)
    B. Body Pains (Pananakit ng Katawan)
    C. Headache (Pananakit ng Ulo)
    D. Fever for the past few days (Lagnat sa nakalipas na
    mga araw)
    2. Have you ever worked together or stayed the same close environment of a confirmed
    COVID-19 case? (May nakasama ka ba o nakatrabahong tao na kunpirmadong may COVID-
    19 / may impeksyon ng coronavirus?)
    3. Have you had any contact with anyone with fever, cough, colds and sore throat in the
    past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo sipon o sakit ng lalamunan
    sa nakalipas na dalawang (2) linggo?
    4. Have you ever travelled to any in NCR aside from your home? (Ikaw ba ay nagpunta sa
    iba pang parte ng NCR o Metro Manila bukod sa iyong bahay? Specify (Sabihin kung
    saan):____________________________________________
    I hereby authorize ELEMENTARY SCHOOL, to collect and process the data indicated herein for the purpose of effecting control of
    the COVID-19 infection. I understand that my personal information is protected by RA 10173. Data Privacy Act of 2012. and that I
    am required by RA 11469, Bayanihan to Heal as One Act. to provide truthful information.
    Signature: ________________________ Date: _______________

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