DTI and DOLE INTERIM GUIDELINES ON

DTI and DOLE INTERIM GUIDELINES ON WORKPLACE PREVENTION AND

WORKPLACE PREVENTION AND CONTROL OF COVID 19
CONTROL OF COVID 19
All visitors shall accomplish the visitor’s checklist Temperature: _______
Health Checklist
All visitors shall accomplish the visitor’s checklist
Temperature: _______
Health Checklist
Name: __________________________________ Sex:____ Age: ___
Name: __________________________________ Sex:____ Age: ___ Residence: _________________________________________________
Residence: _________________________________________________ Nature of Visit: Official If official, fill-in company
Nature of Visit: Official If official, fill-in company Please Check one Personal details below:
Please Check one Personal details below: Company Name: _____________________________________________
Company Name: _____________________________________________ Company Address: ___________________________________________
Company Address: ___________________________________________ 1.Are you YES NO
experiencing a. Sore throat (pananakit ng
1. Are you YES NO (nakakaranas ka ba
experiencing lalamunan/masakit
a. Sore throat (pananakit ng ng) lumunok)
(nakakaranas ka ba lalamunan/masakit
ng) b. Body pains (pananakit ng
lumunok) katawan)
b. Body pains (pananakit ng c. Headache (pananakit ng ulo)
katawan)
c. Headache (pananakit ng ulo) d. Fever for the past few days
d. Fever for the past few days 2.Have you worked together of stayed in the same close
environment of a confirmed COVID-19 case? (May
6.Have you worked together of stayed in the same close nakasama k aba o nakatrabaho na kumpirmadong
environment of a confirmed COVID-19 case? (May may COVID-19 / may impeksyon ng coronavirus?)
nakasama k aba o nakatrabaho na kumpirmadong 3.Have you had any contact with anyone with fever,
may COVID-19 / may impeksyon ng coronavirus?) cough, colds and sore throat in the past 2 weeks?
7.Have you had any contact with anyone with fever, (Mayroon ka bang nakasama na may lagnat, ubo,
cough, colds and sore throat in the past 2 weeks? sipon o sakit ng lalamunan sa nakalipas na dalawang
(Mayroon ka bang nakasama na may lagnat, ubo, lingo?)
sipon o sakit ng lalamunan sa nakalipas na dalawang 4.Have you travelled outside of the Philippines in the last
lingo?) 14 days?(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa
8.Have you travelled outside of the Philippines in the last nakalipas na 14 na araw?)
14 days?(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa 5.Have you travelled to any area in NCR aside from your
nakalipas na 14 na araw?) home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR
9.Have you travelled to any area in NCR aside from your o Metro Manila bukod sa iyong bahay?) Specify
home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR (Sabihin kung saan)
o Metro Manila bukod sa iyong bahay?) Specify
(Sabihin kung saan) I hereby authorize (name of establishment), to collect and process the
data indicated herein for the purpose of effecting control of the
I hereby authorize (name of establishment), to collect and process the
COVID-19 infection. I understand that my personal the information is
data indicated herein for the purpose of effecting control of the
protected by RA 10173, Data Privacy Act of 2012, and that I am
COVID-19 infection. I understand that my personal the information is
required by RA 11469, Bayanihan to Heal as One Act, to provide
protected by RA 10173, Data Privacy Act of 2012, and that I am
truthful information.
required by RA 11469, Bayanihan to Heal as One Act, to provide
truthful information. Signature: _______________________ Date: __________________
Signature: _______________________ Date: __________________

DTI and DOLE INTERIM GUIDELINES ON DTI and DOLE INTERIM GUIDELINES ON
WORKPLACE PREVENTION AND WORKPLACE PREVENTION AND
CONTROL OF COVID 19 CONTROL OF COVID 19

All visitors shall accomplish the visitor’s checklist All visitors shall accomplish the visitor’s checklist
Temperature: _______ Temperature: _______
Health Checklist Health Checklist

Name: __________________________________ Sex:____ Age: ___ Name: __________________________________ Sex:____ Age: ___
Residence: _________________________________________________ Residence: _________________________________________________
Nature of Visit: Official If official, fill-in company Nature of Visit: Official If official, fill-in company
Please Check one Personal details below: Please Check one Personal details below:
Company Name: _____________________________________________ Company Name: _____________________________________________
Company Address: ___________________________________________ Company Address: ___________________________________________

1.Are you YES NO 1.Are you YES NO

experiencing a. Sore throat (pananakit ng experiencing a. Sore throat (pananakit ng
(nakakaranas ka ba lalamunan/masakit (nakakaranas ka ba lalamunan/masakit
ng) lumunok) ng) lumunok)
b. Body pains (pananakit ng b. Body pains (pananakit ng
katawan) katawan)
c. Headache (pananakit ng ulo) c. Headache (pananakit ng ulo)

d. Fever for the past few days d. Fever for the past few days

2. Have you worked together of stayed in the same close 2.Have you worked together of stayed in the same close
environment of a confirmed COVID-19 case? (May environment of a confirmed COVID-19 case? (May
nakasama k aba o nakatrabaho na kumpirmadong may nakasama k aba o nakatrabaho na kumpirmadong
COVID-19 / may impeksyon ng coronavirus?) may COVID-19 / may impeksyon ng coronavirus?)
3. Have you had any contact with anyone with fever, 3.Have you had any contact with anyone with fever,
cough, colds and sore throat in the past 2 weeks? cough, colds and sore throat in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, (Mayroon ka bang nakasama na may lagnat, ubo,
sipon o sakit ng lalamunan sa nakalipas na dalawang sipon o sakit ng lalamunan sa nakalipas na dalawang
lingo?) lingo?)
4. Have you travelled outside of the Philippines in the 4.Have you travelled outside of the Philippines in the last
last 14 days?(Ikaw ba ay nagbiyahe sa labas ng Pilipinas 14 days?(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa
sa nakalipas na 14 na araw?) nakalipas na 14 na araw?)
5. Have you travelled to any area in NCR aside from your 5.Have you travelled to any area in NCR aside from your
home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR
Metro Manila bukod sa iyong bahay?) Specify (Sabihin o Metro Manila bukod sa iyong bahay?) Specify
kung saan) (Sabihin kung saan)
I hereby authorize (name of establishment), to collect and process the I hereby authorize (name of establishment), to collect and process the
data indicated herein for the purpose of effecting control of the data indicated herein for the purpose of effecting control of the
COVID-19 infection. I understand that my personal the information is COVID-19 infection. I understand that my personal the information is
protected by RA 10173, Data Privacy Act of 2012, and that I am protected by RA 10173, Data Privacy Act of 2012, and that I am
required by RA 11469, Bayanihan to Heal as One Act, to provide required by RA 11469, Bayanihan to Heal as One Act, to provide
truthful information. truthful information.

Signature: _______________________ Date: __________________ Signature: _______________________ Date: __________________