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  • Covid Form Template

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    lim.fmc
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    This document is a COVID-19 screening questionnaire containing 4 questions: 1) Are you experiencing any COVID-19 symptoms like fever, cough, body pains, or sore throat? 2) Have you had close contact with a confirmed COVID-19 case in the last 14 days? 3) Have you provided direct care for a COVID-19 patient without proper protective equipment in the last 14 days? 4) Have you traveled outside the Philippines in the last 14 days? The respondent authorizes the collection and processing of this data for contact tracing and control of COVID-19 transmission, with their personal information protected by the Data Privacy Act.

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    Covid form template

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    This document is a COVID-19 screening questionnaire containing 4 questions: 1) Are you experiencing any COVID-19 symptoms like fever, cough, body pains, or sore throat? 2) Have you had close contact with a confirmed COVID-19 case in the last 14 days? 3) Have you provided direct care for a COVID-19 patient without proper protective equipment in the last 14 days? 4) Have you traveled outside the Philippines in the last 14 days? The respondent authorizes the collection and processing of this data for contact tracing and control of COVID-19 transmission, with their personal information protected by the Data Privacy Act.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views1 page

    Covid Form Template

    Uploaded by

    lim.fmc
    This document is a COVID-19 screening questionnaire containing 4 questions: 1) Are you experiencing any COVID-19 symptoms like fever, cough, body pains, or sore throat? 2) Have you had close contact with a confirmed COVID-19 case in the last 14 days? 3) Have you provided direct care for a COVID-19 patient without proper protective equipment in the last 14 days? 4) Have you traveled outside the Philippines in the last 14 days? The respondent authorizes the collection and processing of this data for contact tracing and control of COVID-19 transmission, with their personal information protected by the Data Privacy Act.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Yes No

    1. Are you a. Fever (lagnat)


    experiencing: b. Cough and/or colds (ubo at/o sipon)
    (Nakakaranas ka
    ba ng:) c. Body pains (pananakit ng katawan)
    d. Sore throat (pananakit ng lalamunan/masakit
    lumunok)
    2. Have you had face-to-face contact with a probable or confirmed COVID-19
    case within 1 meter and for more than 15 minutes for the past 14 days?
    (May nakasalamuha ka ba na probable o kumpiramadong pasyente na may
    COVID-19 mula sa isang metrong distansya o mas malapit pa at tumagal ng
    mahigit 15 minuto sa nakalipas na 14 araw?)
    3. Have you provided direct care for a pa ent with probable of confirmed
    COVID-19 case without using proper personal protec ve equipment for
    the past 14 days? (Nag-alaga ka ba ng probable o kumpirmadong pasyente
    na may COVID-19 ng hindi nakasuot ng tamang personal protec ve
    equipment sa nakalipas ng 14 araw?
    4. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay
    nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

    I hereby authorize Western Voca onal Ins tute Inc. to collect and process the data indicated herein for
    the purpose of contract tracing effec ng control of the COVID-19 transmission. I understand that my
    personal informa on is protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be
    destroyed a er 30 days from the date of accomplishment, following the Na onal Archives of the
    Philippines protocol.

    ___________________________________

    Signature above printed name

    Date:

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