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    Health Checklist Form For Visitors: Nakaranas Ka Ba NG Mga Sumusunod: Oo Hindi

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    Coin Char
    This health checklist form requires visitors to provide their personal details such as name, age, sex, city of residence and nature of visit. It then asks a series of yes or no questions regarding any COVID-19 symptoms, exposure to confirmed cases, travel history and existing medical conditions. By signing the form, visitors authorize the Department of Trade and Industry to collect and process this health data for controlling the spread of COVID-19 infection in accordance with relevant privacy laws.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Health Checklist Form For Visitors: Nakaranas Ka Ba NG Mga Sumusunod: Oo Hindi

    Uploaded by

    Coin Char
    35 views2 pages
    This health checklist form requires visitors to provide their personal details such as name, age, sex, city of residence and nature of visit. It then asks a series of yes or no questions regarding any COVID-19 symptoms, exposure to confirmed cases, travel history and existing medical conditions. By signing the form, visitors authorize the Department of Trade and Industry to collect and process this health data for controlling the spread of COVID-19 infection in accordance with relevant privacy laws.

    Original Title

    Re Entry Forms Visitor

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    This health checklist form requires visitors to provide their personal details such as name, age, sex, city of residence and nature of visit. It then asks a series of yes or no questions regarding any COVID-19 symptoms, exposure to confirmed cases, travel history and existing medical conditions. By signing the form, visitors authorize the Department of Trade and Industry to collect and process this health data for controlling the spread of COVID-19 infection in accordance with relevant privacy laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    35 views2 pages

    Health Checklist Form For Visitors: Nakaranas Ka Ba NG Mga Sumusunod: Oo Hindi

    Uploaded by

    Coin Char
    This health checklist form requires visitors to provide their personal details such as name, age, sex, city of residence and nature of visit. It then asks a series of yes or no questions regarding any COVID-19 symptoms, exposure to confirmed cases, travel history and existing medical conditions. By signing the form, visitors authorize the Department of Trade and Industry to collect and process this health data for controlling the spread of COVID-19 infection in accordance with relevant privacy laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Health Checklist Form for Visitors

    (Requirement upon entry)

    Temperature:

    Complete Name: Sex: (F/M) Age:


    (Title) (First Name, Middle Name, Last Name) (Suffix)

    City of Residence:

    Nature of Visit (please check one):


    ▢ Official ▢ Personal If official, fill-in company details below:

    Name of Business:

    Address:
    (House/Building No./Building Name) (Street Name) (Barangay)

    (City/Municipality) (Province) (Region) (Zip Code)

    1. Are you experiencing any of the following: Yes No


    Nakaranas ka ba ng mga sumusunod: Oo Hindi

    a. Sore throat Sakit ng lalamunan

    b. Cough Ubo / Difficulty breathing Hirap sa paghinga

    c. Body pains Sakit ng katawan

    d. Headache Sakit ng ulo

    e. Fever Lagnat

    2. Have you been exposed, worked together or stayed in the


    same close environment of a confirmed COVID-19
    patient/case? May nakasama ka ba or nakatrabahong
    tao na kumpirmadong may COVID-19?
    3. Have you been to a hospital/healthcare facility in
    the Philippines with confirmed case of COVID-19? Ikaw
    ba ay pumunta sa isang ospital o pagamutan sa
    Pilipinas na may kumpirmadong kaso ng COVID-19?

    Please specify location and date (saan at kailan):

    4. Have you had 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 na lalamunan sa nakalipas na 2
    linggo?
    5. Have you travelled outside of the Philippines in the
    last 14 days? Ikaw ba ay nagbiyahe sa labas ng
    Pilipinas sa nakalipas na 14 na araw?

    Please specify location and date of travel (Saan at kalian):

    6. Have you travelled to an area in NCR outside of


    your home? Ikaw ba ay nagpunta sa ibang parte ng
    NCR o Metro Manila bukod sa iyong bahay?

    Please specify location and date of travel (Saan at kalian):

    7. Existing Medical Conditions:


    ▢ Asthma ▢ Heart Disease
    ▢ Chronic lung disease/COPD ▢ Hypertension
    ▢ Diabetes ▢ Others (Please specify: )

    I hereby authorize the Department of Trade and Industry to collect and process the data
    indicated herein for the purpose of effecting control of the COVID-19 infection. I understand
    that provided information shall be processed in accordance with RA 10173 or the Data
    Privacy Act of 2012 and all its related issuances, and that I am required by RA 11469 or the
    Bayanihan to Heal as One Act, to provide truthful information

    Signature: Date:

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