Date:

20 SEP '22 S.M. LAZO MEDICAL CLINIC, INC. SM LAZO MEDICAL CLINIC, INC. Time in:
PEME SCHEDULE CONFIRMATION TO BE FILLED OUT ON THE DAY OF YOUR PEME
Time: 06:00 AM PLEASE PRINT. NO PRINT OUT, NO ENTRY. AND BEFORE ENTERING THE CLINIC.
Temperature:
COVID-19 SCREENING QUESTIONNAIRE
*Information submitted by the Agency*
Please be at the clinic at least 30 minutes before your
Name: Medical Date:
scheduled time. You will only be assisted Agency Mobile No.:
based on your PEME date and time.
Reference No. 363334 I hereby declare that the statements below are true,
accurate and complete. (Aking pinapahayag na ang
AGENCY ADAMSON PHILIPPINES INC.
sagot ko sa mga katanugan ay totoo, tumpak at kumpleto) YES NO
POSITION / JOB APPLIED Master
PEME PACKAGE WEST OF ENGLAND PACKAGE 1. Are you a. Sore throat
experiencing (Pananakit o pamamaga ng lalamunan)
(Ikaw ba ay b. Body pains (pananakit ng katawan)
DEST / VESSEL MT DIGNITY
may nararanasan c. Headache (Pananakit ng ulo)
Mode of Payment Bill to agency
o nakakaranas ng d. Colds and/or coughs (Ubo at/o sipon)
Agency Remarks
mga e. Fever for the past days (Lagnat ng
sumusunod) mga nakaraang araw)
2. Have you worked together or stayed in the same close
APPLICANT NAME CELERES TEODORO SUGANOB environment of a confirmed COVID-19 case? (Mayroon
Birthdate | Age 1963-12-27 | 58 ka bang nakatrabaho o naksama sa bahay na
kumpirmadong may COVID-19 o impeksyon ng Coronavirus?)
3. Have you had any contact with anyone with fever,
*REFER TO THE ONLINE REQUEST FORM (ORF) cough, colds, and sore throat in the past 2 weeks?
APPLICANT GUIDE Please double check that the information provided (Mayroon ka bang nakasama na may lagnat, ubo, sipon o
ON WHAT TO DO/ are complete, true and correct. For corrections, please sakit ng lalamunan sa nakalipas na labing-apat na araw?)
BRING. 4. Have you travelled outside of the Philippies in the last
do the necessary changes on the fields provided.
ORF 363334
PEME DATE 2022-09-20 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas
PLEASE READ,
AGENCY ADAMSON PHILIPPINES INC. sa nakalipas na 14 na araw?)
UNDERSTAND AND
Position/JobApplied Master 5. Have you travelled to any area in NCR aside from your
FOLLOW THE
PEME PACKAGE WEST OF ENGLAND PACKAGE
APPLICANT GUIDE. home? (Ikaw ba ay nagbiyahe sa labas ng iyong
lungsod sa ibang parte ng NCR o Metro Manila bukod
DEST / VESSEL MT DIGNITY

sa iyong bahay?) Specify (Sabihin kung saan)
APPLICANT NAME CELERES TEODORO SUGANOB
I hereby authorize the clinic to IKAW BA AY NABAKUNAHAN NA LABAN
Email Address CREWING@ADAMSONPHIL.COM collect and process the data
Contact Number indicated herein for the purpose of SA COVID-19?
effecting control of the COVID-19
Birthdate 1963-12-27 Age 58 infection. I understand that my
personal information is protect by
OO. PANGALAN NG VACCINE
Gender MALE Civil Status MARRIED the RA 10173, Data Privacy Act of 1st dose/unang dosis
2012, and that I am required by RA
Address 11469, Bayanihan to Heal as One 2nd dose/pangalawang dosis
Act, to provide truthful information.
Place of Birth (Aking pinapahintulutan ang klinika Rehiyon / Lungsod ng pasilidad ng
na kolektahin at iproseso ang data
Nationality Religion na ipahiwatig dito para sa layuning kalusugan ng pagbabakuna
maepektuhan ang pagkontrol sa
Passport No P5443147B impeksyon sa COVID-19. HINDI
Seaman's Book No C1396343 Naiintindi- han ko na ang aking
personal na impormasyon ay
pinoprotektahan ng RA 10173, Data
1755 Taft Avenue, corner J. Nakpil Street, Privacy Act of 2021, at ako ay
inaatasan ng RA 11469, Bayanihan
Malate, Metro Manila 1004 PHILIPPINES to Heal as One Act, na magbigay ng
makatotohanang impormasyon.)
(sa J. Nakpil ang entrance)
(632) 8524 1891-97
Signature over printed name and date Signature over printed name and date
Lagda sa ibabaw ng iyong pangalan at petsa