HEALTH & SAFETY DECLARATION FORM

Complete Name: ______________________________ Date: _________________ Temperature: ___________

Sex: __________________ Age: ______________ Cellphone No.: ___________________

Home Address: _________________________________________________ Time-In: _____________ Time-Out: ______________

Company Name & Address: ____________________________________________________________________________________

Status: Employee Personal Visit Company Name & Address:

Others
Job Applicant Official Visit
Nature of Visit: Work Interview/Orientation If Others, state reason here:
Others
Appointment Pickup/Delivery
Please answer these questions to the following health-related questions:
1. Are you experiencing? Fever Yes No New Loss of Taste or Smell Yes No
Sore Throat Yes No Chills Yes No
Body Pains Yes No Nausea, Diarrhea, Vomiting Yes No
Headache Yes No Difficulty of breathing or
Yes No
Muscle ache Yes No shortness of breath
2. Have you been in contact or stayed in a close environment with a person potentially exposed to Yes No
COVID-19
3. Did you and/or
have any confirmed COVID-19
contact with someone person,withorfever,cough,colds,
anyone related orsore hadthroat
contact inwith
the pasta confirmed
2 weeks?COVID-19 patient (friend, relative, Yes No
4. Have you travelled outside the Philippines in the last 14 days? Yes No
5. Have you travelled to any area in NCR aside from your home in the last 14 days? Yes No
6. List the places you've been to yesterday
(For contact tracing purposes):
ADDITIONAL HEALTH & SAFETY QUESTIONNAIRE
1. How many are you in the house?
2. Is any one currently ill in the household? Yes No
If yes, what are the symptoms?
3. How long has the symptom existed?
4. Has a medical worker/doctor examined the patient? Yes No
5. Can you give an overview of the examination result? Yes No
6. Have you attended a mass gathering/meeting in the last 14 days? Yes No
If Yes, where and when?                                                                                                                                                                     
7. Did anyone from your household attended a mass gathering/meeting in the last 14 days? Yes No
If Yes, where and when?                                                                                                                                                                     
By signing this document, I hereby authorize the company 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). I know that I am required to provide truthful information
as required by RA 11469 (Bayanihan as One Act).
I certify that as of today, I am submitting this Health & Safety Check Declaration and Questionnaire voluntarily and with full knowledge and understanding of its
safety purpose. It is also my genuine desire to preserve good health and well- being of everyone in my workplace and my home.
The Company had completely and repeatedly provided and advised me of all COVID-19 required safety and precautionary measures. For my part, I completely
understand and I am fully aware of the risks and safeguards I need to undertake for my safety and those of my co-workers.
In rendering this disclosure, I hereby render the Company free and harmless from any claim of any nature whatsoever. I also declare that I have conducted myself
in a safe and healthy manner inside the company as well as outside, recognizing that any affliction that I gather outside may harm my fellow workers in the office.

Printed Name: Signature & Date:

 HEALTH & SAFETY CHECK DECLARATION FORM

Complete Name: ___________________________Date: _________________ Temperature: _________________

Sex: __________________ Age: _____________Cellphone No.: ___________________
Home Address: ____________________________Time-In: _____________ Time-Out: _________________
Company Name & Address: _______________________________________________________________________________
ature: _________________

ut: _________________
____________________________________
 HEALTH & SAFETY CHECK DECLARATION FORM
Complete Name: ______________________________ Date: _________________
Sex: __________________ Age: ______________ Cellphone No.: ___________________
Home Address: _____________________________________________ Time-In: _____________
Company Name & Address: _______________________________________________________________________________

Status: Employee Personal Visit Others

Job Applicant Official Visit
Nature of Visit: Work Interview/Orientation Others
Appointment Pickup/Delivery
Please answer these questions to the following health-related questions:
1. Are you experiencing? Sore Throat Yes No Headache?
Body Pains Yes No Fever for the past days?
2. Have you been in contact or stayed in a close environment with a person potentially exposed to
COVID-19 and/or confirmed COVID-19 person, or anyone related or had contact with a confirmed COVID-19 patient
(friend, relative, community colleague, neighbor)?

3. Did you have any contact with someone with fever,cough,colds, sore throat in the past 2 weeks?

4. Have you travelled outside the Philippines in the last 14 days?

5. Have you travelled to any area in NCR aside from your home in the last 14 days?
6. List the places you've been to yesterday
(For contact tracing purposes):
ADDITIONAL HEALTH & SAFETY QUESTIONNAIRE
1. How many are you in the house?
2. Is any one currently ill in the household?
If yes, what are the symptoms?
3. How long has the symptom existed?
4. Has a medical worker/doctor examined the patient?
5. Can you give an overview of the examination result?
6. Do you yourself manifest the following same symptoms:
Fever Yes No New Loss of Taste or Smell
Dry Cough Yes No Chills
Headache Yes No Nausea, Diarrhea, Vomiting
Head or muscle aches Yes No Difficulty breathing or shortness of
Sore Throat Yes No breath
7. Have you attended a mass gathering/meeting in the last 14 days?
If Yes, where and when?                                                                                                                                                                     
8. Did anyone from your household attend a mass gathering/meeting in the last 14 days?
If Yes, where and when?                                                                                                                                                                     
By signing this document, I hereby authorize the company to collect and process the data indicated herein for the purpose of
COVID-19 infection. I understand that my personal information is protected by RA 10173 (Data Privacy Act of 2012). I know th
provide truthful information as required by RA 11469 (Bayanihan as One Act).
I certify that as of today, I am submitting this Health & Safety Check Declaration and Questionnaire voluntarily and with full kn
understanding of its safety purpose. It is also my genuine desire to preserve good health and well- being of everyone in my wo
The Company had completely and repeatedly provided and advised me of all COVID-19 required safety and precautionary mea
completely understand and I am fully aware of the risks and safeguards I need to undertake for my safety and those of my co-
In rendering this disclosure, I hereby render the Company free and harmless from any claim of any nature whatsoever. I also d
conducted myself in a safe and healthy manner inside the company as well as outside, recognizing that any affliction that I gat
my fellow workers in the office.

Printed Name: Signature & Date:

RM
Temperature: _________________
_____________
Time-Out: _________________
___________________________________

If Others, state reason here:

adache? Yes No
er for the past days? Yes No
d to
ed COVID-19 patient Yes No

eks? Yes No

Yes No
Yes No

Yes No

Yes No
Yes No

e or Smell Yes No
Chills Yes No
a, Vomiting Yes No
hing or shortness of Yes No
reath
Yes No
                                       
Yes No
                                       
ated herein for the purpose of effecting control of the
Privacy Act of 2012). I know that I am required to

aire voluntarily and with full knowledge and

ell- being of everyone in my workplace and my home.
d safety and precautionary measures. For my part, I
my safety and those of my co-workers.
any nature whatsoever. I also declare that I have
ing that any affliction that I gather outside may harm