Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

Region VII – Central Visayas Region VII – Central Visayas
DIVISION OF CEBU PROVINCE DIVISION OF CEBU PROVINCE

EMPLOYEE/VISITORS SCREENING QUESTIONAIRE EMPLOYEE/VISITORS SCREENING QUESTIONAIRE

(Please fill in the box of your answer) Time: _______ Temperature:________ (Please fill in the box of your answer) Time: _______ Temperature:________
Name:___________________________________ Position:____________ Sex:______ Age:______ Name:___________________________________ Position:____________ Sex:______ Age:______
Residence:_______________________________________________________________________ Residence:_______________________________________________________________________
Contact Number: _________________________________________________________________ Contact Number: _________________________________________________________________
Status: Teaching Personnel ⃝ Non-teaching Personnel ⃝ Parent ⃝ Student ⃝ Status: Teaching Personnel ⃝ Non-teaching Personnel ⃝ Parent ⃝ Student ⃝
If Employee(Teacher/Administratortaff) If Employee(Teacher/Administratortaff)
Division Office Pesonnel ⃝ Section; ___________________ Division Office Pesonnel ⃝ Section; ___________________
District/School Personnel ⃝ School: ____________________ District; ____________ District/School Personnel ⃝ School: ____________________ District; ____________
If Visitor: Nature of Visit: Official ⃝ If Visitor: Nature of Visit: Official ⃝
Personal ⃝ Personal ⃝
If official, fill in company details below If official, fill in company details below
Company Name: __________________________________________________ Company Name: __________________________________________________
Company Address: ________________________________________________ Company Address: ________________________________________________
Yes No Yes No
Sore Throat Sore Throat
Are you Experiencing: (Sakit sa tutunlan) Are you Experiencing: (Sakit sa tutunlan)
(Nakasinati ba ka ug: Body Pains (Nakasinati ba ka ug: Body Pains
(Sakit sa Lawas (Sakit sa Lawas
Headache Headache
(Sakit sa ulo) (Sakit sa ulo)
Fever for the past few days Fever for the past few days
(Hilanat sa imaging mga adlaw) (Hilanat sa imaging mga adlaw)
Have you worked together or stayed in the same close environment of a Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case?(Nakakuyog ba kag tawo or katrabaho sa usa ka confirmed COVID-19 case?(Nakakuyog ba kag tawo or katrabaho sa usa ka
kumpirmadong naay COVID-19/naay impeksyon sa coronavirus) kumpirmadong naay COVID-19/naay impeksyon sa coronavirus)
Have you had any contact with anyone with fever,cough,colds and sore Have you had any contact with anyone with fever,cough,colds and sore
throat in the past 2 weeks(naa ba kay nakakuyog nga naay hilanat,ubo,sip- throat in the past 2 weeks(naa ba kay nakakuyog nga naay hilanat,ubo,sip-
on ug sakit sa tutunlan sa niaging duh aka simana?) on ug sakit sa tutunlan sa niaging duh aka simana?)
Have you travelled to any area in the Philippines in the last 14 days? Have you travelled to any area in the Philippines in the last 14 days?
(Nakalarga baka sa gawas Pilipinas sa niaging 14 ka adlaw?) (Nakalarga baka sa gawas Pilipinas sa niaging 14 ka adlaw?)
Have you travelled to any area in the Philippines aside from your home? Have you travelled to any area in the Philippines aside from your home?
(nakabiya baka sa laing lugar diri sa Pilipinas gawas sa inyong puluy-anan?) (nakabiya baka sa laing lugar diri sa Pilipinas gawas sa inyong puluy-anan?)
Specify(asa man nga lugar):_____________________________________ Specify(asa man nga lugar):_____________________________________

I hereby authorized Department of Education, to collect and process the data indicated herein for I hereby authorized Department of Education, to collect and process the data indicated herein for
the purpose of effecting control of the COVID-19 infection. I understand that my personal 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, information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA
Bayanihan to Heal as One Act, to provide truthful information. 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature Over Printed Name:____________________________ Date: _____________________ Signature Over Printed Name:____________________________ Date: _____________________