Employees Health Declaration Form

Employees Health Declaration Form
Full Name
Given NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Facebook Account
Just input your Facebook user name
Date and Time of Work Schedule
MonthDayYear
2 digit month, 2 digit day, 4 digit year1
Hour MinutesAM/PM Option
Are you experiencing:
Rows YES NO
Fever
Cough and/or Cold
Body Pains
Sore Throat

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.
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Clear
Should be Empty:

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