NGCP HEALTH AND TRAVEL DECLARATION FORM ‘Annex Arev2 GUEST FULLNAME: TA Jey MARE} _SBX:_10 AGE: 24_NATIONALITY: BMAP}? (Lest Name, First Name, Midna) (CURRENT ADDRESS IN THE PHILIPPINES: _RuPOK GOSES, SLAG AMLAL! NEG OR (louse number, sree, barangay and municipal) CONTACT NO. IN THE PHILIPPINES: 0930S480S3@_E-MAIL ADDRESS: Jevmeavktablate@)gnuil com CONTACT PERSON IN NGCP: HG, _ALwws Rey S- Aviso 0 PURPOSE OF VISIT IN NGCP:—_.DORK DATES OF VISIT IN NGC VENUE GOP —Aeata_56- ‘TRAVEL HISTORY: What countries / lies ia the Philippines have you visited in the past four (4) weeks? cemeeioiaiSS ieee ht ee ‘SCREENING QUESTIONS YES NO. ToDo you have Tver HATS Sal oF ger Dau 57°C cpa TO days 7 (OR have you taken ant-fever medication the past 10 da Have you had cough and/or fc of breathing nthe past 10 days Z 3. Have You Rad any close contact with a SUSPECTED COVID-19 patient (patient with ever, T ‘ough, andor difficulty of breathing) inthe past 14 days? a Fo Have you had any close woutact witha PRODADLE COVID-T9 pation (suspected patent Ai ‘ested for COVID-19 but with negative inconclusive result inthe 5 Hlave you had any close contact with a CONFIRMED COVID-19 patient in the past 14 z {emt es aa REMINDERS: ‘+ Your addresses and contact information are vital in the conduct of CONTACT TRACING for containment of the occurrence of COVID-19 incase a postive casei found. + Foryour addresses: Your complete address will include house nfoumber,stret, barangay, nd municipality. For transient visitor, ican be the name of hotel where you ae staying in the Philippines. ‘+ For your contact umber: Your contact number must be the local mobile number, landline, or mobile ‘numberof friend/relative where you are staying inthe Philipines. DATA PRIVACY Inline withthe Data Privacy Act of 2012 (DPA) please be mformed that NGCP wil be hunding your personal ond health Information n relation othe COVID-19 Assessment All personal data acquired by NGCP from this asessment shal only bbe used for COVID-19 screening purposes by authorized NGCP representatives and shall not be further procesed oF disclosed without the consent ofthe signatory, unless required by government instrumentates for purposes of contact tracing. Retention of your personal information shall be for @ period of ne (1) year from the date of submission. Beyond this ices cen ra wy we rand of your persia informacion from ehis transection shall be digpoced of ‘according tothe Company's procedures ‘The above information provided in this Health and Travel Declaration Form are true, complete and correct. I understand that I may be held lawfully liable for any omission, false information or ‘misinterpretation made Rerein, especialy if such action resulted to under exposure of workers unl the general public to the risks of COVID-19. Further, I allow NGCP to process my personal