ST.

MICHAEL’S COLLEGE
Iligan City

COLLEGE OF CRIMINOLOGY

CONTACT TRACING FORM

Name: __________________________________________ Date: ____________________________

Age: __________ Contact No.: _____________________ Department: ________________________
Address: _______________________________________________ Temperature: _______________
1. Are you experiencing: YES / NO
a. Sore throat
b. Body pain
c. Headache
d. Cough and colds
2. Have you been stayed in the
same close environment of a
confirmed Covid 19 case?
3. Have you had any contact with
anyone with fever, cough, colds,
& sore throat in the past 2 weeks?
4. Have you travelled outside of the
city or NCR in the last 14days?

I hereby authorize SMC Campus to collect and process the data indicated herein for the purpose of
effective control of the covid 19 infection. I understand that my personal information to provide truthful
information.

____________________________________________ ___________________________
Signature over printed Name Date