NGCP HEALTH AND TRAVEL DECLARATION FORM ‘Annex A yev2 GUEST FULLNAME: NUPA MYCAKEL ChtlO_L_sex: Mace: Lb wationauiry: £MPIO __ (Last Name, FirstName, Mdde inital) da (CURRENT ADDRESS IN THE PHILIPPINES: PURDE Toots _C1LK® UM WEE. OR. (Mouse number, street, Barangay and municipal) CONTACT NO. INTHE PHILIPPINES:0A 6FFZ®O5 g. all aDDRESS: ee CONTACT PERSON IN NGCP: EN& Av PURPOSE OF VISIT IN NGCP: DATES OF VISIT IN NCCP ‘TRAVEL HISTORY: What counties / cies the Plppines have you vse nthe pas four () weeks? ‘SCREENING QUESTIONS. Yes T Bu youve fever that equal to or higher than 37.0°C im the post 10 days? ‘ORhave you taken anti-fever medication the past 10 days? [2 Have you had cough and/or dificulty of breathing in the past 10 days? 1 '3, Have you had any close contact witha SUSPECTED COVID-19 patient (patient with Fever, cough, and/or difficulty of breathing) in the past 14 days? 7 Have you had any close contact with a PROBABLE COVID-19 patient euspected patient | tested for COVID-19 but with negative/inconclusive pending result in the past 14 days?_| [5 Have yourhad any close contact with a CONFIRMED COVID-19 patient inthe past 14 L days? REMINDERS: ‘© Your addresses and contact information are vital inthe conduct of CONTACT TRACING for containment of ‘the occurrence of COVID-19 in case a positive case is found. ‘+ Foryouraddresses: Your complete address wil include house nSoumber, street, barangay, and municipality For transient visitor, itcan be the name of hotel where you are staying in the Vilippines. ‘+ For your contact number: Your contact number must be the local mobile number, landline, or mobile ‘numberof friend,/relative where you are staying inthe Philippines. NINN DATA PRIVACY {Inline with che Data Privacy Act of 2012 (DPA) please be informed that NGCP wil be handling your personal ond hecth ‘information in relation to the COVID-19 Assessment All personal data acquired by NGCP from tis assessment shall only be 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 instrumentals for purposes of contact tracing. Retention of our personal information shall befor «period of one (1) year from the date of submission. Beyond {hie daa eh documant and any othar record of your parsonal information from tie transaction ahall be dcpoced of ‘ccording to the Company's procadures. The above information provided in this Health and Travel Declaration Form are true, complete and correct. I understand that 1 may be held lawfully liable for any omission, false information or ‘isinter pretation made herein, espectilly if suet uctiou resulted Wy under expusure uf workers und the general public to the risks of COVID-19. Further, I allow NGCP to process my personal information stated here oggrdance wth he company's Dat Privacy equations Buea HORE ‘Signature of Guest over Printed Name, Date