Ref.

#: CMO-F-077
Rev. #: 0
Rev. Date: 10 November 2020

HEALTH CHECKLIST
FOR PROJECT SITE

PROJECT NAME: Temperature: _______

Contractor / Company Date: (Petsa:)

Name of Worker/Staff Age / Sex
(Pangalan ng manggawa) (Edad / Kasarian)
YES(Oo) NO(Hindi
)
1. Are you experiencing: a. Sore throat (Pananakit ng lalamunan)
(Nakararanas ka ba ng:) b. Body Pain (Pananakit ng katawan)
c. Headache (Pananakit ng ulo)
d. Fever for fast few days.
(Lagnat sa nakalipas na mga araw)
2. Have you worked together or stayed in the same close environment of
a confirmed COVID-19 case? (May nakasama ka ba o nakatrabaho na
kumpirmadong my COVID-19 / may impeksyon ng Cororna Virus)
3. Have you had any contact with anyone with fever, cough, colds and
sore throat in the past 2 weeks? (Mayroon ka banabg nakasama na may lagnat,
ubo, sipon o sakit ng lalamunan sa nakalipas na dalawang (2) lingo?)
4. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba
ay nagbiyahe sa labas ng Pilipinas sa nakalilpas na 14 na araw?)

5. Have you travelled to any area in NCR aside from your home? (Ikaw ba
ay nagpunta sa iba pang parte ng NCR o Metro Manila buokod sa iyong bahay?
Specify (Sabihin kung saan): ___________________
6. Had a COVID-19 Test done prior to entry in the construction site?
(Nagkaroon ka ba ng testing para sa COVID-19 bago pumasok sa site?) If YES,
When: (Kung OO, Kailan)? ___________

Note:
This is valid only upon entry. If the worker or staff went out of the vicinity of the construction site for more than
24hrs, he/she should again must fill-up this form and submit to the Safety Officer on site.

Regular temperature check is mandatory before entering the site and/or the workplace. Workers / Staff
temperature must be logged at the workers / staff log-book or attendance sheet for monitoring

I hereby authorized _______________to collect and process the data indicated herein for the purpose of
effective control of the COVID-19 infections. I understand that my personal information is protected by RA
10173, Data Privacy Act of 2019, and that I am required by RA 11496, Bayanihan to Heal as One Act, to
provide truthful information

Signature: __________________________ Noted by: _____________________________

(Signature of Worker / Staff) (Contractor Project / Construction Manager)