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Employee Health Declaration Form

The employee health declaration form collects information about employees such as name, age, sex, address, department, and emergency contacts. It asks whether employees have been in contact with COVID-19 patients, experienced COVID-19 symptoms, or have medical conditions like diabetes, heart disease, or asthma. Employees must declare if their responses are true and accurate. The employer needs this information to ensure employee and workplace safety according to law. Any medical information disclosed will remain confidential.

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Jessielyn Mulawin
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572 views2 pages

Employee Health Declaration Form

The employee health declaration form collects information about employees such as name, age, sex, address, department, and emergency contacts. It asks whether employees have been in contact with COVID-19 patients, experienced COVID-19 symptoms, or have medical conditions like diabetes, heart disease, or asthma. Employees must declare if their responses are true and accurate. The employer needs this information to ensure employee and workplace safety according to law. Any medical information disclosed will remain confidential.

Uploaded by

Jessielyn Mulawin
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

EMPLOYEE HEALTH DECLARATION

Name: Contact Person in case of Emergency (Name &


Number):

Age: Contact Person in case of Emergency (Name &


Number):

Sex: Contact Number:

Complete Address:

Department: Position:

Mode of Transportation Going to Work:

□ Personal vehicle □ Company vehicle □ Commute

Questionnaire:

□ Yes
Have you been in close contact with a COVID-19 patient?
□ No
□ Yes
Have you been a PUI during ECQ?
□ No
□ Yes
Have you been diagnosed to have COVID-19?
□ No
□ Yes
Are you pregnant?
□ No
Have you been diagnosed with any of the following?
(encircle what applies)
- Hypertension
- Diabetes Mellitus
□ Yes
- Bronchial Asthma
□ No
- Heart Disease
- Cancer
- Autoimmune Disease
- Chronic Renal Disease
Are you experiencing any of the following symptoms?
(encircle what applies)
- Cough
- Colds
- Breathlessness
- Fever □ Yes
- Headache □ No
- Sore throat
- Diarrhea
- Body pain
- Weakness
- Loss of sense of smell and taste

As your employer, Philippine Allied Enterprises Corporation is responsible for your health and welfare while at work. Therefore, it is important that
we are aware of any condition, medical or otherwise, which may have an impact on you and your fellow employees in the workplace. This
Questionnaire is not designed as a tool to discriminate, rather to create awareness and to ensure everyone’s safety pursuant to Sec. 4(g) of R.A.
11332 (“Law on Reporting of Communicable Diseases”). Any information that you may disclose in this form shall remain confidential and shall only
be disclosed to the proper health authorities as provided by Sec. 6 of R.A. 11332 on the “Mandatory Reporting of Notifiable Diseases and Health
Events of Public Concern.”
EMPLOYEE HEALTH DECLARATION

Declaration: I hereby certify that the above information is true and correct.

As your employer, Philippine Allied Enterprises Corporation is responsible for your health and welfare while at work. Therefore, it is important that
we are aware of any condition, medical or otherwise, which may have an impact on you and your fellow employees in the workplace. This
Questionnaire is not designed as a tool to discriminate, rather to create awareness and to ensure everyone’s safety pursuant to Sec. 4(g) of R.A.
11332 (“Law on Reporting of Communicable Diseases”). Any information that you may disclose in this form shall remain confidential and shall only
be disclosed to the proper health authorities as provided by Sec. 6 of R.A. 11332 on the “Mandatory Reporting of Notifiable Diseases and Health
Events of Public Concern.”

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