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Santa Rosa Manpower Training Center

CONTRACT TRACING / HEALTH SURVEY

Name:___________________________________ Gender:______________
Address:_________________________________ Age:______________
Contact No:_______________________ Email Address:____________________________

Candidate for Assessment Trainer/Assessor/Personnel

Qualification :____________________________________________________________

Date:______________________ Temperature:_________________________

SYMPTOMS (Sintomas) (Lagyan ng Check)

Fever
Lagnat
Dry Cough
Tuyong Ubo
Sore Throat
Namamagang Lalamunan
Shortness of Breath
Hirap sa paghinga
Loss of Smell or Taste
Pagkawala ng pang-amoy o panglasa
Fatigue
Pagkapagod
Aches and Pains
Pananakit ng katawan
Runny Nose
Sipon
Diarrhea
Pagdudumi
Headache
Pananakit ng ulo
NONE OF THE ABOVE
WALA SA MGA NABANGGIT
Have you worked together or stayed in some close environment
with a confirmed COVID-19 case?
May nakasama kaba o naka trabahong tao na kumpirmadong may
COVID-19?
Have you had any contact with anyone with fever, cough, colds,
and sore throat in past 2 weeks?
Mayroon ka bang nakasama na may lagnat, ubo, sipon, o sakit sa
nakalipas na 2 linggo?
Have you travelled to any area aside from home?
Ikaw ba ay nag punta sa ibang lugar bukod sa inyong bahay?
If YES Please Specify:

I hereby authorized the Technical Education and Skills Development Authority (TESDA) to collect and process the data indicated here in
the purpose of effecting control of the COVID-19 infection, I understand that my personal information is protected by R.A. 10173 or Data
Privacy Act of 2012, and that I am required by R.A.11469 or Bayanihan to Heal as One Act to provide truthful information.

_______________________

Signature