HEALTH QUESTIONNAIRE (Talatanungan ukol sa kalusugan): (English)

What are our legal obligations in this COVID-19 situation?

Please read carefully (Basahin ng Mabuti)
(Tagalog) Under RA11332, we are all obliged to be “socially and medically responsible”. Section 9
Bilang mamamayan, ano ang ating legal obligations sa panahon ng COVID-19? of the same law requires all persons to disclose his or her recent travel history with the
frontline health workers.
Ayon sa RA 11332, mayroon tayong obligasyon na maging “socially and medically
responsible”. Ayon sa Section 9, sa panahon ngayon, ipinagbabawal ang hinding mag-
Moreover, the following persons are also required to inform the authorities, if they are
bigay impormasyon sa ating mga frontline health personnel ukol sa kanyang recent travel
considered as a suspect case, probable case and a confirmed case.
history.
Sa mga taong kabilang sa suspect case, probable case at confirmed case, sila rin ay *A patient will be classified as "SUSPECT" if they fall under any of the three:
may obligasyong mag bigay impormasyong sa mga doktor, medical personnel, ospital o 1. Patient has the following symptoms:
frontline health personnel. A. Fever of at least 38 degrees C
B. Cough
*Kabilang sa klasipikasyong SUSPECT CASE kung: C. Throat Pain
1. Mayroong influenza-like illness na: And either of the two:
A. Lagnat (38C) at A. Has travel history or lives in community with local COVID-19 transmission
B. Ubo/pananakit ng lalamunan within 14 days since start of symptoms;
At kabilang sa isa sa mga nasa ibaba: B. Had close contact with a confirmed or probable COVID-19 case within 14
A. Naglalakbay o nanirahan sa isang lugar na may ulat ng lokal na days since start of symptoms
transmisyon ng sakit na COVID—19 sa loob ng 14 na araw bago 2. Patient has the following symptoms:
nagsimula ang mga sintomas; A. Fever
B. Nagkaroon ng close contact sa isang CONFIRMED o PROBABLE CASE B. Cough
ng COVID-19 sa loob ng 14 na araw bago nagsimula ang mga sintomas. C. Difficulty breathing
2. Ang taong: And is any of the following:
A. May lagnat o A. 60 years old and above
B. Ubo o B. Has preexisting condition
C. Hirap sa paghinga C. Has sensitive pregnancy
D. A health worker
At kabilang sa isa sa mga nasa baba:
3. Patient experiences sudden onset of lung illness with severe symptoms of
A. Edad 60 taon at pataas
unknown origin and needs hospitalization
B. Mayroong iba pang sakit
*A person will be classified as "PROBABLE" if he/she was earlier tagged as a "suspect" and
C. Mayroong maselan na pagbubuntis
has the following:
D. Health worker
- Still undetermined COVID-19 results
3. Nagkaroon ng biglaang karamdaman sa baga na may malubhang sintomas na
- Test was not done in an official laboratory with RT-PCR test (reverse transcription
hindi matukoy ang kadahilanan at kinakailangang ma-ospital.
polymerase chain reaction, considered the “gold standard” in COVID-19 testing);
*Kabilang sa klasipikasyong PROBABLE CASE kung:
- remains untested
A. Ikaw ay suspect patient;
*A person will be considered a CONFIRMED COVID-19 case if RT-PCR testing shows
B. Hindi tiyak ang resulta ng testing; at
positive result for coronavirus.
C. Ginawa ang iyong test sa hindi opisyal na laboratory na gumawa ng RT-PCR test.
*Kabilang sa klasipikasyong CONFIRMED CASE kung ang iyong resulta sa RT-PCR
What are the penalties for the violation of RA11332?
TESTING AY PASITIBO SA COVID-19.
Ano ang parusa sa hindi pag sunod sa RA11332?
Any person found to have violated Section 9 of this Act shall be penalized with a fine of not
less than Twenty thousand pesos (₱20,000.00) but not more than Fifty thousand pesos
Parusang pagkakulong ng isa hanggang anim na buwan o multa mula Php20,000.00
(₱50,000.00) or imprisonment of not less than one (1) month but not more than six (6)
hanggang Php50,000.00 ang hindi pagsunod at paglabag sa legal obligation na ito.
months, or both such fine and imprisonment, at the discretion of the proper court.
PAALALA LAMANG: Ang mga impormasyong ibinibigay ninyo ay isa sa mga requirements
para sa inyong pre-employment contract at para na ring ipagbigay impromasyon ang Note: The information given by the applicants is a requisite for their pre-employment and
inyong employers. for the knowledge of their employers as well.
Please answer truthfully (Sagutan ng buong katotohanan)

Name (Pangalan): ____________________________________________________________

1. Have you experienced any of the following signs and symptoms in the past 14
days? (Nitong mga nakaraang 14 na araw nakaramdam ka ba ng kahit ano sa
mga sumusunod na simtomas?):

- Fever (Lagnat)
- Coughing and Sneezing (Pag ubo at pagbahing)
- Colds and Sore throat (SIpon at masakit na lalamunan)
- Shortness of breath/difficulty of breathing (Kapos o hirap sa paghinga)
- Diarrhea/Loose Bowel Movement (Pagtatae)

( ) YES/ OO ( ) NO/ HINDI

2. Where did you stay for the last 14 days? (Saan ka naglagi nitong nakaraang 14 Client/Visitor Contact Tracing Form
araw give address?):
Full Name (Last, Given, Middle): Temperature:

Complete current Address (House No., St., Brgy.,

Date of Visit (MM/DD/YY):
Municipality/City, Province):
Time of Visit:
3. Do you have a household member that was diagnosed with COVID-19 in
the past one month? (Me nakasama ka ba sa bahay na na diagnosed o nag Mobile/ Phone Number: Seating/Table No/Location:
positive sa COVID-19 nitong nakalipas na isang buwan?): E-mail Address:
( ) YES/ OO ( ) WALA/ NONE

4. Do you have a household member that is presently sick or experiencing I hereby authorize MMLCI, to collect and process the data indicated herein for the
cough or fever? purpose of contact tracing effecting control of the COVID-19 transmission. I
(Me kasama ka ba ngayon sa bahay na me sakit tulad ng ubo at lagnat?) understand that my personal information is protected by RA 10173 or the Data
Privacy Act of 2012 and that this form will be destroyed after 30 days from the date
of accomplishment, following the National Archives of the Philippines protocol.
( ) OO/ YES ( ) WALA/ NONE
Signature :
The above declarations are certified to be true and correct. (Ang aking mga deklarasyon
ay totoo at tama).

_____________________________________________________
PRINTED NAME AND SIGNATURE (BUONG PANGALAN AT LAGDA)

_________________
DATE (PETSA)