Daily Health Questionnaire Fill-Up

1. Check the box below if you have any of the following.

2. Body temperature upon coming in the office.

& leaving

3. List of places you have been and full name of persons you have contact with/encountered from the time you left ESC office up to the time you have arrive ESC office the next morning.

4. Did anyone you have contact with have any signs of cough or fever? If yes, kindly indicate his/her full name and a description of the interaction.

5. Check the boxes below if you have followed today and yesterday the following safety precautions to avoid the virus.

I hereby declared that all information provided are true and correct within my best abilities.

Printed Name

Date

Reviewed by:

Jerry Marte/Carlos Critica

Date

6/F Cyberone Building, 11 Eastwood Ave., Eastwood City Cyberpark Bagumbayan, Quezon City Philippines 1110 +632 464 9383 | www.escsteelphil.com