ee BRIDGING Powe 8 PROGRESS NGCP HEALTH AND TRAVEL DECLARATION FORM Nees GUEST _ PULLNAME Sabdaalet. Maeie SoltarosEX. MAGE: 27 NATIONALITY: (Lost Name, First Name, Middle Ini!) ‘CURRENT ADDRESS IN THE PHILIPPINES: _ Os lan -o& i ls ee CONTACT NO. INTHE PHILIPPINES:09 304 '5_ E-MAIL ADDRESS: CONTACT PERSON IN NGCP: : PURPOSE OF VISIT IN NGCP:, es DATES OF VISIT IN NCCP: VENUE: ‘TRAVEL HISTORY: What countries / cites in the Philippines have you vist in the past four (A) weeks? ‘SCREENING QUESTIONS —— ves T Rayon fave fear Hath anal nr higher than 27 R60 Ta Pea pa TAR? t OR have you taken ani-fever medication the past 10 days? Have you kad cough and/or difculty of breathing inthe past 10 days? "3 Have Vou had any close contact with a SUSPECTED COVID-19 patient (patient with ever, “ough and/or difey of breathing) n the past 14 days? Have yo hoe any else eantact with a PROBABLE COVIDIS patent (ausperted patient tested for COVID-19 but with negative/inconclusive/pending result) in he past 4 days? Have you had any close contact witha CONFIRMED COVID-19 patient inthe past I+ days? AINA SE REMINDERS: *\, Your adresses and contact énformation are vital in the conduc of CONTACT TRACING for containment of, Le ocrurrence of COVID-19 in case a positive cases found + Nfoeyouraddresses: Your complete address will include house nBoumber, street, barangay, nd municipality For eranslent vate, Ian be the name of hotel where you are srying Inthe Paine. ‘© For your contact number: Your contact number must be the local mobile number, landline, or mobile umber of fiendreative where you ae staying inthe Philippines. DATA PRIVACY In line wih oe Data Privacy Act of 2012 (DPA), please be normed that MGCP wil be handing your personal and heath Information in relation o the COVID-19 Assessment Al personal data acquired by NGCP from this assessment shall only ‘be used for COVID-19 screening purposes by authorized NCP representatives and shall not be further processed oF dlisclosed wiehout the consen of the signatory, unless required by government insrumentalitis for purposes of contact tracing Retention of our personal information shal befor @pered of oe (1) year from the date of submission. Beyond {hes data chs documont and any other record of your portal information from thie reneoction shall be depoeed of according v0 che Company’ procedures. ‘The above information provided in this Health and Travel Declaration Form are true, complete and correct. | understand that I may be held lawfully able for any omission, false information or Iisinverpretation nude herein, especially if such action resulted to under expusute of workers wind ‘the general public to the risks of COVID-19. Further, I allow NGCP to process my personal {information stated here in accordance with the company’s Data Priva. Signature of Gu@st over Printed Name, Date