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Health Declaration Form: (Nakakaranas Ka Ba NG)

The document is a health declaration form for employees regarding COVID-19, where employees are asked to provide their name, contact details, and answer questions about any COVID-19 symptoms they have experienced or potential exposure to the virus. Employees must disclose their temperature and sign the form, authorizing the company to collect their personal health information to help prevent the spread of COVID-19 in the workplace.

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Elimer Teves Espina
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2K views1 page

Health Declaration Form: (Nakakaranas Ka Ba NG)

The document is a health declaration form for employees regarding COVID-19, where employees are asked to provide their name, contact details, and answer questions about any COVID-19 symptoms they have experienced or potential exposure to the virus. Employees must disclose their temperature and sign the form, authorizing the company to collect their personal health information to help prevent the spread of COVID-19 in the workplace.

Uploaded by

Elimer Teves Espina
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Health Declaration Form

COVID-19
The safety of the employees remains as the top priority of the Company. As the outbreak of Coronavirus Disease 2019
(COVID-19) continues, the Company continues to be vigilant in preventing its spread and reduce the potential risk of
exposure of everyone in the workplace. Please answer this Form to help us take the necessary precautionary measures to
protect you and everyone in the Company premises.

Temperature: ________

Name: ________________________________________________________________________ Sex: _______ Age: _______

Residence: ___________________________________________________________________________________________

Nature of Visit: Official Personal If official, fill-in the company details below -

Company Name: ______________________________________________________________________________________

Company Address: ____________________________________________________________________________________

Yes No

a. Sore throat (pananakit ng lalamunan / masakit lumunok)


1. Are you experiencing:
b. Body pains (pananakit ng katawan)
(nakakaranas ka ba ng)
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 or 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 salabas
ng Pilipinas sa nakalipas na 14 na araw?)

I hereby authorize Ayala Property Management Corporation (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, and that I am required by RA 11469, Bayanihan to Heal as One Act, to
provide truthful information.

Signature: _________________________________________________________________ Date: _____________________

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