Name*

First Name Last Name

Gender:*

Male Female

Mobile Number:*

Address:*

Street Address

Street Address Line 2

City State / Province

1. Are you experiencing any of the following? (nakakaranas ka ba ng alinman sa mga sumusunod)

a. Sore Throat (pananakit ng lalamunan/masakit lumunok)*

YES NO

b. Body Pains (pananakit ng katawan)*

YES NO

c. Headache (pananakit ng ulo)*

YES NO

d. Fever for the past few days (lagnat sa nakalipas na mga araw)*

YES NO

2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? (May nakasama ka ba or nakatrabahong tao na kumpirmadong may COVID-19 / may impeksyon ng corona virus?)*

YES NO

3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas na dalawang (2) linggo?)*

YES NO

4. Have you travelled outside of the Philippines in the last 14 days? (Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)*

YES NO

I hereby authorize United Pentecostal Church Batangas City, to collect my data indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Host as One Act, to provide truthful information.

Health Checklist