Date*

Date

Name*

First Name Last Name

Department

Body Temperature

Celsius/ Fahrenheit

Dear Cheiler,

Kindly accomplish this form and submit to HR prior reporting back to work and/or execution of official business. Thank you!

Do you have any of the following symptoms during the past 14 days?

If YES, do not come to work. Let us know if you are not feeling well and contact your local healthcare provider.

Please mark if you have had contact with a COVID-19 PUI or PUM for the last 14 days.

YES NO

If YES, kindly notify the HR Department and contact your local healthcare provider.

Have you gone through Antigen or Antibody Testing for COVID-19?

YES NO

When?*

MM/DD/YYYY

Where?

Hospital, Clinic, etc.

What was the result of the test?

Thank you!

By affixing your signature below, you agree that CHEIL PH may contact, use, and or disclose your personal and/or sensitive data for health and safety purposes.

Signature

Clear

Self-Check Questionnaire