Form SW01.

REV00

Covid-19 Checklist

Please fill out the following completely:

1. Video Call Date:

2. Manager/Supervisor Name and Current Complete Address

with Barangay Name: Cyril Gabral

3. Staff Name and Current Complete Address with Barangay

Name: Heherson Juan/Tandang Sora, Quezon City

4. Video Call done via: ___Skype; ___Facetime; ___ Viber; ___

Zoom; _________Others

5. Exact time and duration of Video Call: From ______ To ______

6. Companions at home and possible future companions at

home. Ling, Greg, Meree

7. When was the last time you went out of the house, where did
you go and why: March 31-Buy groceries.

8. At the moment, check if you have the following: ___ fever;

___cough; ___ colds; ___headache; ___sore throat; ___body
ache; ___constant fatigue; ___difficulty breathing; None.
9. Anyone in your household experienced symptoms under
#8? None.

10. Have you sought COVID19 testing ___yes; Pno

11. Is anyone in your barangay COVID19 positive Pyes;

___no
12. Have you recently traveled outside your barangay
___yes; Pno. If yes, when __________

13. Is there any member of your household with exposure

to COVID19 patients? None.

14. Other COVID19 related concerns the office should know

about: None.