HEALTH CHECKLIST

NOTE: All Officials. Employees and visitors are required to accomplish this form prior to entry to company premises
for monitoring purposes
Temperature:

Name: Sex: Age:

Residence:
Nature of Visit: Official: 
Please check one If official, fill-in company
details below
Personal: 
Company Name:

Y N
1. Are you es o
experiencing: a) Sore throat (pananakit ng lalamunan / masakit
(nakakaranas ka ba lumunok)  
ng:) b) Body pains (pananakit ng katawan)
 
c) Headache (pananakit ng ulo)
 
d) Fever for the past few days (Lagnat sa nakalipas na
mga araw)  
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na  
kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)

3. Have you had any 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 ng lalamunan sa nakalipas ng dalawang (2) lingo?)

4. Have you travelled outside of the Philippines in the last 14 days? (Ikaw ba
ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)  

5. Have you travelled to any area in NCR aside from your home?  
(Ikaw ba ay nagpunta sa iba pang parte ng NCR 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 COVID-19 infection. I understand that my personal
information is 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 truthful information.

Signature: Date:

HEALTH CHECKLIST
 NOTE: All Officials. Employees and visitors are required to accomplish this form prior to entry to company premises
for monitoring purposes
Temperature:

Name: Sex: Age:

Residence:
Nature of Visit:
Please check one
Official: 
If official, fill-in company
details below
Company Name: Personal: 

Company Address:

Y N
1. Are you es o
experiencing: e) Sore throat (pananakit ng lalamunan / masakit
(nakakaranas ka ba lumunok)  
ng:) f) Body pains (pananakit ng katawan)
 
g) Headache (pananakit ng ulo)
 
h) Fever for the past few days (Lagnat sa nakalipas na
mga araw)  
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na  
kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)

3. Have you had any 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 ng lalamunan sa nakalipas ng dalawang (2) lingo?)

4. Have you travelled outside of the Philippines in the last 14 days? (Ikaw ba
ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)  

5. Have you travelled to any area in NCR aside from your home?  
(Ikaw ba ay nagpunta sa iba pang parte ng NCR 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 COVID-19 infection. I understand that my personal
information is 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 truthful information.

Signature: Date: