REPUBLIC OF THE PHILIPPINES )

CITY OF QUEZON CITY ) SS.

UNDERTAKING

I, _____________________, of legal age, single/married, Filipino, with

office/residence and postal address at ___________________________________, in
accordance with law, do hereby depose and say – THAT:

1. I am an employee of ___________ located at _______________________;

2. I understand the need of the Government to open up the economy slowly amid the
Covid 19 pandemic;
3. I believe that the workplace has been Covid 19 Virus free since before the lock
down;
4. I understand that the Management will be here to guide, to warn & to provide basic
security to all of us against Covid 19;
5. the following Advisories in relation to Covid 19 have been explained to us:
a. Advisory No. 04-2020 (Guidelines on Covid 19 Prevention & Controls in Work
Place).
b. Advisory No. 18 – 2020 (Guidelines on the Cost of Covid 19 Prevention &
Control Measures).
6. the Management has reminded us over and over again the danger posed by Covid
19 and the only way to avoid it is through self-consciousness of all the safety
measures all the time;
7. I am aware of the terms and conditions laid down by the Government are for the
prevention of Covid 19 and for the promotion of health and safety, improvements of
public morals, maintenance of peace and order, preservation of comfort and
convenience of the inhabitants and the promotion of general welfare in general;
8. Thus, in adherence to the foregoing, I hereby undertake that I shall:
a. voluntary report to work upon the approval & request of the Management;
b. take extra precautions against Covid 19 with the full understanding that I am
responsible for my own well-being, of my own family and that the well-being
of my co-workers and their families;
c. follow whatever Health Protocol that is being implemented by the
Management (i.e. - Temperature Check, Face Mask Requirements, Social
Distancing, hand cleaning, disinfectants, among other measures);
d. voluntarily absent myself from work for any symptoms that my may feel that
are Covid 19 related for the safety of all;
e. agree to be put into Flexible Working Conditions and/or even on Floating
Status as the needs arise;
9. A violation of any of the foregoing undertaking shall be sufficient ground for
termination or any such sanctions as Management may impose under the
circumstances.
10. That I execute this affidavit voluntarily and in order to attest the truth of the above
facts for all legal intents and purposes it may serve;

_________________________
Employee Name/Date

SUBSCRIBED AND SWORN to before me this ___ day of _______ in the City of
___________, affiant having exhibited to me his/her ___________________ ID bearing No.
_______________ issued by the ___________________ and valid until ______.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2020.
REPUBLIKA NG PILIPINAS)
SIUDAD NG ____________) S.S.

PAGSASAGAWA

Ako, ___________________________, nasa wastong gulang, may/walang asawa,

Pilipino at nakatira sa __________________________________, alinsunod sa batas, gawin ito
at magsabi, NA:

1. Ako ay isang empleado ng _______________________ na makikita at mapupuntahan

sa _________________________;
2. Naiintindihan ko ang pangangailangan ng Gobyerno na buksan dahan dahan ang
Ekonomiya sa kalagitnaan ng lagim ng Covid 19;
3. Naniniwala akong walang Covid 19 sa aming lugar ng pagtratrabahuhan bago pa man
mag lock down;
4. Nainintindihan ko na ang Pamunuan ay nandito upang magbigay gabay, babala at
bigyan kami ng seguridad laban sa Covid 19;
5. Nai-paliwanag sa amin ang 2 importanteng Advisory galing sa DOLE:
a. Advisory #04-2020 (Guidelines on Covid 19 Prevention & Controls in Work Place)
b. Advisory #18–2020 (Guidelines on the Cost of Covid 19 Prevention & Control
Measures).
6. Walang katapusan paalala at babala ang nanggagaling sa Pamunuan patungkol sa
panganib na maidudulot ng Covid 19; na ang tanging paraan ng pagsugpo nito ay ang
pagiging maingat sa lahat ng oras kontra Covid 19;
7. Aking alam na ang mga tuntunin at Kondisyon binaba ng ating Gobyerno sa
pamamagitan ng aming Pamunuan para sa pag-iwas at pagkalat ng Covid 19 ay para sa
pagsulong ng kalusugan at kaligtasan, pagpapabuti ng pamplublikong moral,
pagpapanatili ng kapayapaan at kaayusan, ng ginhawa at kaginhawaan ng mga
naninirahan at pagtataguyod ng pangkalahatang kapakanan;
8. Sa gayon, bilang pagtibay sa mga naisaad, ay aking isasagawa ang mga sumusunod:
a. boluntaryong pagpasok alinsunod sa pag-apruba at kahilingan ng Pamunuan;
b. kusang pagliban sa aking trabaho kapag may maramdaman anuman ng
sintomas ng Covid 19 para sa kaligtasan ng lahat;
c. sagutin ng buong katapatan ang pang-araw-araw ng Health Check List;
alinsunod sa patakaran ng D.O.H. para sa anuman benepisyo ng Philhealth;
d. Pag-iigihin ang pag-iingat laban sa Covid 19 na may lubos na pang-unawa na
ako lang ang responsible sa aking kalusugan, ng aking pamilya, at ng
kapakanan ng aking mga kasama sa trabaho at ang kanilang mga pamilya;
e. Sundin ang anumang panuntunan kalusugan na ipinapatupad ng kumpanya (i.e.-
pagsusuri ng temperatura, pagsuot ng face mask, pagsunod sa social distancing,
paglilinis ng kamay, paggamit ng dis-infectant, at iba pang mga panukala);
f. Sumasang-ayon mailagay sa tinatawag na “Flexible Working Arrangement” o
“Floating Status” depende sa pangangailangan ng pamunuan;;
9. Ang hindi ko pagsunod o hindi pagtupad sa anumang nakasaad ay sapat na dahilan
upang ako ay matanggal sa trabaho o patawan ng Pamunuan ng anumang nararapat na
parusa.
10. Na nilgadaan at isinasakatuparan ko ng kusang loob ang Pagsasagawa na ito upang
patotohanan ang mga nabanggit na katotohanan para sa legal na hangarin at layunin na
maihahatid nito;

_________________________
LAGDA/PETSA

Lumagda at nanumpa sa aking harapan ngayong ika-____ ng _______ taon ________

dito sa Siudad ng _____________ at kung saan ipinakita sa akin ang kanyang
___________________ ID numero bilang __________________ na ipinagkaloob noong ika-
____ ng ____________ taon ______ ng (sangay ng gobyerno).

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2020.