Republic of the Philippines OFFICE OF THE CITY HEALTH OFFICER San Pablo City HEALTH CHECKLIST Name: Residence: Contact No. Personal _Ifofficial, fill-in establishment details below: ‘Temperature: (nakakaranes ka bo ne) Ly leona uo rakotabahorg ino kunpracorg iy COVI-8/ may tetany oon) [sew ny nagovana sa Woes Pinner rs ksi: nae wow) a Jolo}o)olo}o}oks oJojojolojojolog hy authorize City Health Offic, to collect and process the data indicated het ‘understand that my personal information is protected by RA 10173, a Privacy ‘Act provide truthful information, for the purpose of effecting contol of the COVID-19 infection. 1 ‘Act of 2012, and that Iam required by RA 11469, Bayanihan t Heal st One Signature: Da RECOMMENDATION: —— Return Home / Release For Isolation for 14 days For repeat Antibody Test For RT-PCR RECOMMENDATION: —— Return Home / Release For repeat Antibody Test For Isolation for 14 days For RT-PCR MD ee ee