Attachment 2: Health Checklist Disclosure Form

Temperature: _____________

Name/s:           Date: ______________________

Company: __________________________________ Time: ______________________ 

For students, guests and clients please fill in the following details:
Address_____________________________________   Email: ____________________________
Contact Number:   

YES NO
1. Are you currently experiencing, or have you a. Fever (lagnat)
experienced in the past 14 days, any of the b. Cough and/or colds (ubo
following symptoms? (nakakaranas ka na ng:) at/o sipon)
 Body pains (panankit ng
katawan)
 Sore throat (pananakit ng
lalamunan/masakit lumunok)
2. Have you had face-to face contact with a probable or confirmed COVID-19 case
within 1 meter and for more than 15 minutes for the past 14 days? (May
nakasalamuha kaba na probable o kumpirmadong pasyente na may Covid-19
mula sa isang metrong distansya or mas malapit pa at tumagal ng mahigit 15
minuto sa nakalipas na 14 araw?)
3. Have you or anyone you immediately know had a confirmed case of COVID-19
Or In the past 14 days, have you been in close proximity to anyone who was
experiencing any of the above symptoms or has experienced any of the above
symptoms since your contact? (Maroon ka bang nakasama na may lagnat, ubo,
sipon o sakit ng lalamunan sa nakalipas na dalawang 2 lingo?)
4. In the past 14 days, have you been on a commercial flight or traveled outside
of the Philippines? In the past 14 days, have you been in close proximity to
anyone who has been on a commercial flight or traveled outside of the
Philippines? (Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14
na araw?)
5. Have you had any contact with OFW or Locally Stranded Individuals (LSI)in the
past 2 weeks? (Mayroon ka bang nakasam na OFW or LSI sa loob ng dalawang 2
lingo?)
6. Have you travelled outside in the current city/municipality where you reside? (Ikaw
ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo? Sabihin kung saaan.)

I hereby authorize Senior High School of Xavier 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.  This form will be destroyed after 30
days from the date of accomplishment, following the National Archives of the Philippines protocol. 

Signature: