BRIDGING POWERE PROGRESS NGCP HEALTH AND TRAVEL DECLARATION FORM RepATev2 GUEST sTeennnoc? kyael Gs sex:M_ace: At nationaLiry: EIUEINS (LastName, Firs Nome. Middle nil) ‘CURRENT ADDRESS IN THE PHILIPPINES: B€r/ ODBLLAS TANIAY CITY Neco. (Gouse number, sereet. barangay and municipalty) CONTACT NO. IN THE PHILIPPINES: C4&e24l-4244 e.MalL ADDRESS: FOPLANEEL ADAM ste CONTACT PERSON IN NGCP: ENG. ALAM Risy $- AN ISD. PURPOSE OF VISITIN NGCP:, ‘DATES OF VISIT IN NGCP:. VENUE: ADA - "TRAVEL HISTORY: What countries / cities in the Philippines have you visited inthe past four (4) weeks? FULLNAM! ‘SCREENING QUESTIONS YS Do you have fever thats equalto or higher than 37°C nthe pac 10 day OR have you taken ant-ever medication the past 10 days? Have you ha cough and/or difficulty of breathing in the past 10 days? ‘ave you ha any lose contact witha SUSPECTED COVID-19 patient (patient with fever, cough, and/or difficulty of breathing) inthe past 14 days? ‘ave you had any close contact witha PROBARLE QOVID-19 patient (suspected patient S tested for COVID-19 but with ngative/Inconcusive/pending result) in the past 14 days? Have you had any close contact witha CONFIRMED COVID-19 patient nthe past 14 - a vf oly REMINDERS: ‘+ Your addresses and contact information are vital in the conduct of CONTACT TRACING for containment of the accurrence of COVID-19 in case a positive cases Found ‘© Foryour addresses: Your complete address will include house ndoumber, street, barangay, and municipality. For ancient vitor, Ieeaa be me name or howe where you are staying tn Ue Flippin. ‘+ For your contact number: Your contact number must be the lol mobile number, landline, or mobile ‘number of frend/relative where youare staying in the Philipines. DATA PRIVACY Inilne wit he Duss Pri Aut 2022 (DPA), please be yfrmed that NCCP wil be handing your personal and health Information in rection tothe COVID-19 Assessment. Al 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 processed or Gscosed without the consent ofthe signatory unless required by government intrumentaties for purposes of contact ‘racing. Retention of our personal information shal befor @pertod of one (1) year from the dave of submission. Beyond ths deta his document and any other record of your personal information from this transaction shall be disposed of ‘according to the 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 ‘isinterpretation made herein, especially if such action resulted to under exposure of workers and the general public to the risks of COVID-19. Further, I allow NGCP to process my personal information stated herein agordance with the company's Data regulations.