Employees Health Declaration Form

Please answer the following questions

Rows	YES	NO
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?
Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper personal protective equipment for the past 14 days?
Have you traveled outside the Philippines for the past 14 days?
Have you travelled outside the current city/municipality where you reside?

If yes, specify which city/municipality you went :
By submitting this form, I have authorize _____________________ to collect and process the data indicated herein for the purpose of contact tracing effecting control of the COVID-19 transmission.
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