DATE:

FAR EASTERN UNIVERSITY

HUMAN RESOURCE DIVISION TIME IN: TIME OUT:
HEALTH CHECKLIST FORM
TEMPERATURE:
NAME: (Last Name, First Name, M.I.) SEX: AGE:
ADDRESS: (Permanent)
PURPOSE: (Please specify) CLASSIFICATION:
☐ WORK ☐APPOINTMENT ☐ JOB APPLICATION ☐ENROLLMENT ☐EMPLOYEE ☐FACULTY ☐ STUDENT ☐ALUMNI
☐ PICKUP/DELIVERY ☐ OTHERS, specify: _______________________________ OTHERS, specify: _________________________________________________
(For entrants connected with FEU) (For entrants NOT connected with FEU)
COMPANY NAME:
ID NUMBER:
COMPANY ADDRESS:
INSTITUTE/DEPARTMENT:
MOBILE NO
MOBILE NO:
YE NO YE NO
S S
1. Are you Sore throat (Pananakit ng lalamunan / 2. Have you worked together or stayed in the same close environment
experiencing: masakit lumunok) of a confirmed COVID-19 case? (May nakasama ka ba or
(Nakararanas nakatrabahong tao na kumpirmadong may COVID-19 / may
Body pains (Pananakit ng katawan)
ka ba ng:) impeksyon ng coronavirus?)
Headache (Pananakit ng ulo) 3. Have you had any contact with anyone with fever, cough, colds, and
sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may
Fever for the past few days (Lagnat sa
lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2)
nakalipas na mga araw)
linggo?)
Colds (Sipon)
Diarrhea (Pagtatae) 4. Have you travelled outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na
Difficulty in breathing (Nahihirapan sa pag
araw?)
hinga)
If yes, specify (Sabihin kung saang bansa)______________________
Shortness of breath (Kinakapos ng hininga)
Fatigue (Pagkapagod) 5. Have you travelled to any area in NCR aside from your home? (Ikaw
ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa
iyong bahay?) If yes, specify (Sabihin kung saan): _________________
Loss/decrease in hearing (Pagkawala or 6. Did you use public transportation going to FEU? (Sumakay ka ba sa
paghina ng pandinig) pambulikong sasakyan papuntang FEU?)
If yes, please indicate type of public transport
__________________
If no, please indicate means of transport _____________________
Loss/decrease in smell (Pagkawala or paghina 7. Have you attended a mass gathering in the last 14 days? (Dumalo
ng pang-amoy) ka ba sa isang pagtitipon sa nakalipas na 14 na araw?)
If yes, where and when? ____________________________________

I hereby authorize FAR EASTERN UNIVERSITY, to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal
information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature over Printed Name Date

DATE:
FAR EASTERN UNIVERSITY
HUMAN RESOURCE DIVISION TIME IN: TIME OUT:
HEALTH CHECKLIST FORM
TEMPERATURE:
NAME: (Last Name, First Name, M.I.) SEX: AGE:
ADDRESS: (Permanent)
PURPOSE: (Please specify) CLASSIFICATION:
☐ WORK ☐APPOINTMENT ☐ JOB APPLICATION ☐ENROLLMENT ☐EMPLOYEE ☐FACULTY ☐ STUDENT ☐ALUMNI
☐ PICKUP/DELIVERY ☐ OTHERS, specify: _______________________________ OTHERS, specify: _________________________________________________
(For entrants connected with FEU) (For entrants NOT connected with FEU)
COMPANY NAME:
ID NUMBER:
COMPANY ADDRESS:
INSTITUTE/DEPARTMENT:
MOBILE NO
MOBILE NO:
YE NO YE NO
S S
3. Are you Sore throat (Pananakit ng lalamunan / 2. Have you worked together or stayed in the same close environment
experiencing: masakit lumunok) of a confirmed COVID-19 case? (May nakasama ka ba or
(Nakararanas nakatrabahong tao na kumpirmadong may COVID-19 / may
Body pains (Pananakit ng katawan)
ka ba ng:) impeksyon ng coronavirus?)
Headache (Pananakit ng ulo) 3. Have you had any contact with anyone with fever, cough, colds, and
sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may
Fever for the past few days (Lagnat sa
lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2)
nakalipas na mga araw)
linggo?)
Colds (Sipon)
Diarrhea (Pagtatae) 4. Have you travelled outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na
Difficulty in breathing (Nahihirapan sa pag
araw?)
hinga)
If yes, specify (Sabihin kung saang bansa)______________________
Shortness of breath (Kinakapos ng hininga)
 Fatigue (Pagkapagod) 5. Have you travelled to any area in NCR aside from your home? (Ikaw
ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa
iyong bahay?) If yes, specify (Sabihin kung saan): _________________
Loss/decrease in hearing (Pagkawala or 6. Did you use public transportation going to FEU? (Sumakay ka ba sa
paghina ng pandinig) pambulikong saskyan papuntang FEU?)
If yes, please indicate type of public transport
__________________
If no, please indicate means of transport ___________________
Loss/decrease in smell (Pagkawala or paghina 7. Have you attended a mass gathering in the last 14 days? (Dumalo
ng pang-amoy) ka ba sa isang pagtitipon sa nakalipas na 14 na araw?)
If yes, where and when? ___________________________________

I hereby authorize FAR EASTERN UNIVERSITY, to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal
information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature over Printed Name Date