BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER

DECLARATION FORM (Work-From-Home during Covid-19 pandemic)

For the Month of April 2021
To concerned staff: In view of the Alternative Work Schedules, please fill up the information below if you utilized the
Work-From-Home scheme:

NAME OF STAFF: JANVEN G. NERA

POSITION: NURSE I
OFFICE/ AREA OF ASSIGNMENT: COVID ICU
Schedule of Work From Home: April

____ I hereby certify that I belong to the vulnerable group of employees of BGHMC for which I opted the Work-
From-Home scheme because of the call for Stay-At-Home for said group during the Covid-19 pandemic.
Check as applicable the reason why you belong to the vulnerable group:
___ 60 years old and above
___ with immunodeficiency (specify: _______________________________)
with comorbidity/ies (specify:Ischemic heart disease, angina pectoris, hypertension 2)
___ pregnant
___ with other health risk/s (specify: ________________________________)
___ others (specify: ______________________________________________ )

____ I worked from home because our office/unit/department implemented the WFH scheme on a staggered basis,
for which I committed to stay-at-home as I am expected to be available during work hours and be on call when
needed.

Further, I declare that during my WFH schedule:

I did not go out of my residence nor visit places (market, grocery etc.)
I did not practice my profession in clinics/other hospitals/other places nor meet clients/patients.
___ I have left residence/practiced my profession/met clients/patients on: (*Given this, I shall waive
accountability of the hospital should I get infected with Covid-19 or get apprehended by authorities. My
salaries and benefits may also be affected depending on the recommendation of the supervisor and/or
appraisal of management if reason is acceptable)
Date/s Reason Remarks of Supervisor if reason is
acceptable or not

*acceptable reason: personal medical check-up

I certify the correctness of the information provided above. I authorize the head/representative of the agency to
validate/verify my whereabouts. I agree that any misinterpretation on my end may be taken against me.

__________JANVEN G. NERA________________________
Signature over printed name of staff/Date

Comment/s: __________________________________________________________________________________
___________________________________________________________________________________________

________________________________________________
Signature over printed name of immediate supervisor/Date