DATE ( 記入日 ) . .

CEBU MITSUMI, INC.

Sabang, Danao City, Cebu, Philiipines

COVID-19 HEALTH DECLARATION

I. PERSONAL DATA　個人データ
(Please Print All Information)（もれなく記入ください。）
NAME（氏名） : NATIONALITY（国籍） :
COMPANY NAME（会社名） :
CONTACT NUMBER（電話番号） :
Cell Phone #（携帯電話番号） :
Stay in Cebu（宿泊先） : (Hotel) (Staff House)
Work S'dule in FCB　（滞在日数） : -
II. HEALTH DATA　健康データ
1. HEALTH DISCLOSURE: Please check the following:
YES NO YES NO
Tested positive or presumptively positive with the Fever
Coronavirus or been identified as a potential Chills
carrier of the COVID-19 virus or similar Body Malaise / Body aches
communicable illness (“Coronavirus”): Headache
With manifestations of Covid-19 symptoms for Chest pain / Chest discomfort
the past 14 days. Cough
With close contact with Confirmed Covid-19. Colds / Runny nose
Difficulty breathing
Dizziness

2. COMPANY COVID-19 PREVENTIVE MEASURES:

I consent to having my temperature taken by any representative or agent of Cebu Mitsumi, Inc.
prior to entering, during and while I’m at the premises of the company;
I will wear mask at all times and will take responsible preeventive measures implemented by CEBU
MITSUMI, INC.
I will not go to the company and initiate self-isolation in case I feel sick or not feeling well during
my visit; immediately notify CEBU MITSUMI, INC. and consent to be given immediate medical
care including Covid Antigest test.

= = ONLY OFFICE USE = = This is to certify that the above data are true and correct
DIV. MGR GA MGR GA STAFF 上記記述には間違いはございません。
RECEIVE => CHECK => FILE Signed:
DATE. DATE. DATE. 署名

PRINTED NAME OVER SIGNATURE