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    Employee Health Declaration Form

    Uploaded by

    kaizer infinity
    This document is an employee health declaration form used by GCW9 Land Inc. to collect health information from employees for contact tracing and controlling the spread of COVID-19. It asks employees to provide their name, date of shift, and address. It then asks them to check yes or no boxes to indicate if they are experiencing COVID-19 symptoms, had contact with a confirmed case, provided direct care without protection, traveled outside the country or city in the past 14 days. It states that personal information will be protected and destroyed after 30 days according to data privacy laws.

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    Employee Health Declaration Form

    Uploaded by

    kaizer infinity
    10 views1 page
    This document is an employee health declaration form used by GCW9 Land Inc. to collect health information from employees for contact tracing and controlling the spread of COVID-19. It asks employees to provide their name, date of shift, and address. It then asks them to check yes or no boxes to indicate if they are experiencing COVID-19 symptoms, had contact with a confirmed case, provided direct care without protection, traveled outside the country or city in the past 14 days. It states that personal information will be protected and destroyed after 30 days according to data privacy laws.

    Original Description:

    for COVID Form regarding your health

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    © © All Rights Reserved

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    This document is an employee health declaration form used by GCW9 Land Inc. to collect health information from employees for contact tracing and controlling the spread of COVID-19. It asks employees to provide their name, date of shift, and address. It then asks them to check yes or no boxes to indicate if they are experiencing COVID-19 symptoms, had contact with a confirmed case, provided direct care without protection, traveled outside the country or city in the past 14 days. It states that personal information will be protected and destroyed after 30 days according to data privacy laws.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    10 views1 page

    Employee Health Declaration Form

    Uploaded by

    kaizer infinity
    This document is an employee health declaration form used by GCW9 Land Inc. to collect health information from employees for contact tracing and controlling the spread of COVID-19. It asks employees to provide their name, date of shift, and address. It then asks them to check yes or no boxes to indicate if they are experiencing COVID-19 symptoms, had contact with a confirmed case, provided direct care without protection, traveled outside the country or city in the past 14 days. It states that personal information will be protected and destroyed after 30 days according to data privacy laws.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Employee Health Declaration Form

    Full Name (Last, Given,Middle): Date of Shift:


    Address:   Employee Health Declaration Form
    Please place a check under your response.     Full Name (Last, Given,Middle): Date of Shift:
    N
    Yes Address:  
          o
    a. Fever     Please place a check under your response.    
    b. cough N
    Yes
          o
    1. Are you experiencing: and/or colds    
    a. Fever    
    c. Body Pains    
    b. cough
    d. Sore throat    
    1. Are you experiencing: and/or colds    
    2. Have you had face to face contact with a probable or
    c. Body Pains    
    confirmed COVID-19 case within 1 meter and for more
    d. Sore throat    
    than 15 minutes for the past 14 days?    
    2. Have you had face to face contact with a probable or
    3. Have you provided direct care for a patient with
    confirmed COVID-19 case within 1 meter and for more
    probable or confirmed COVID-19 case without using
    than 15 minutes for the past 14 days?    
    proper personal protective equipment for the past 14
    days?     3. Have you provided direct care for a patient with
    probable or confirmed COVID-19 case without using
    4. Have you travelled outside the Philippines in the last 14
    proper personal protective equipment for the past 14
    days?    
    days?    
    5. Have you travelled outside the current city where you
    4. Have you travelled outside the Philippines in the last 14
    reside?    
    days?    
    5. Have you travelled outside the current city where you
    I hereby authorize GCW9 Land Inc., to collect and process the data reside?    
    indicated herein for the purpose of contact tracing, effecting control of
    the COVID-19 transmission. I understand that my personal information
    is protected by RA 10173 or the Data Privacy Act of 2012 and that this I hereby authorize GCW9 Land Inc., to collect and process the data
    form will be destroyed after 30 days from the date of accomplishment, indicated herein for the purpose of contact tracing, effecting control of
    following the National Archives of the Philippines protocol. the COVID-19 transmission. I understand that my personal information
    is protected by RA 10173 or the Data Privacy Act of 2012 and that this
    form will be destroyed after 30 days from the date of accomplishment,
    following the National Archives of the Philippines protocol.
    Signature

    Signature

    Employee Health Declaration Form


    Full Name (Last, Given,Middle): Date of Shift:
    Address:   Employee Health Declaration Form
    Please place a check under your response.     Full Name (Last, Given,Middle): Date of Shift:
    N
    Yes Address:  
          o
    a. Fever     Please place a check under your response.    
    b. cough N
    Yes
          o
    1. Are you experiencing: and/or colds    
    a. Fever    
    c. Body Pains    
    b. cough
    d. Sore throat    
    1. Are you experiencing: and/or colds    
    2. Have you had face to face contact with a probable or
    c. Body Pains    
    confirmed COVID-19 case within 1 meter and for more
    d. Sore throat    
    than 15 minutes for the past 14 days?    
    2. Have you had face to face contact with a probable or
    3. Have you provided direct care for a patient with
    confirmed COVID-19 case within 1 meter and for more
    probable or confirmed COVID-19 case without using
    than 15 minutes for the past 14 days?    
    proper personal protective equipment for the past 14
    days?     3. Have you provided direct care for a patient with
    probable or confirmed COVID-19 case without using
    4. Have you travelled outside the Philippines in the last 14
    proper personal protective equipment for the past 14
    days?    
    days?    
    5. Have you travelled outside the current city where you
    4. Have you travelled outside the Philippines in the last 14
    reside?    
    days?    
    5. Have you travelled outside the current city where you
    I hereby authorize GCW9 Land Inc., to collect and process the data reside?    
    indicated herein for the purpose of contact tracing, effecting control of
    the COVID-19 transmission. I understand that my personal information
    is protected by RA 10173 or the Data Privacy Act of 2012 and that this I hereby authorize GCW9 Land Inc., to collect and process the data
    form will be destroyed after 30 days from the date of accomplishment, indicated herein for the purpose of contact tracing, effecting control of
    following the National Archives of the Philippines protocol. the COVID-19 transmission. I understand that my personal information
    is protected by RA 10173 or the Data Privacy Act of 2012 and that this
    form will be destroyed after 30 days from the date of accomplishment,
    following the National Archives of the Philippines protocol.
    Signature

    Signature

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