Heath Chek [Tompesare——] Heath Chet te eee Name eas Ration ‘Contact No. atime Contact No. ‘we of Var OE fame of van OO aes otc in company eae aon Nae pa, vot OREO rata hn cpa eee omg ane Conn Nine ‘ae sane ee = ee =a cee es ‘Shatelaann/csts| 1 Ce teow tamenn/met | os co S con oy oa wy = (panankit ng kata = panonakit ag koswan) = ie tee pamanatit ng wo) a nanakit ng alo) a agar sa abapas na mga || Fever er the past few age (Cagna se nataipas mr mee | | CD aw He you work ogee or jd in he same clove evant 3 nfined COVID-19 case May nla he vo naan |) | ‘uaa ey COVID-19/maytpehyon conan?) "lve you word gather raped in he sae cos eva a ‘nme COVID.IB ce? (ay nate ha bo narhong to |) | ‘Lampang may COVID-18 Fey ipo ne corer” 1H you ad any Sat with jon wi Tove, coh ca nd sre inthe pst? wes agro bang maka na may lg | | th sion oa llamo enka ng daa 2) go?) "Tle you ai any cont with anyone with over, ough, ali nd sare throat inthe pat? wes? (eyron hr hang natsane me may gmat | cy | tpn tat tamanan malar ng dawn (2) bo?) (Uae a ay naga aban Ppa a natalia na 14m 0) | Tr Tle you tale ide of te Piliines et Tt 14 da? haw boy raxbahe va labs ne Pipa a nabs nea?) |) | ‘Hive you velo any aa i NCR wide iow yur one? o be napa ab pong pare ngNCKo Mer Man nd 8 org aay?) Spates) "Have you ave To yaa in NCW sie om your ome? ae bow napa svi pang pare ng NCR Mero Mart bad song ue Spec Suna "hrebyahriz [nae of exashnent clean res he data indict ere the [Eprsed by RA 10173 Das Pacy Ac of 2012 and tt am ed by RA 110, hereby autora of sabia cob and races thet ct hei fr tbe {2 rowete ty RA TOIT, Data Pvacy Act of 2012, and tht Cam gue 8) RA TI, bf ue Ae po lr Ben hee Oe fe pe nl — = Sipe at Meath Chek [Tompenere=———] Heath Che tee eee ame ar Ratio ‘Contact No. Dali Contact No. tune of Var OE fame of van Of ante otc in conpny ea aon Na pa, VOR OBE Orta hn cpa eee Compu ane Conn Nine ‘ae sane eS = 1 ey expetaceg| > foe =a cae eS ‘Shathlaann/ccs| 1 Ce (aowtatameun/meit | a cos S com oto oa wy = (pananakit ng katawan) 2 panonakis ag kosawan) = ie tee pamanakit ng wo) a nanakit ng alo) a Cigna s0obapas na mga | | a Fever fr the past few ape (Cagna 0 nates mr mee | | CD awh Have you waved gta o saya he same slow envionment oa nfined COVID-19 case? (May nla he bo naan |) | ‘etapa ey COVID.19/may iphone cornarirs?) 7 lve you work gather aye in he sae cows evioamea a ‘nfm COVID-I9 cae? (ay natnaa ha bao marae? |) | ‘Lamping may COVID-18 may ipeyen ne corer”) 1H you ad any sat wth jon wi Tove, coh cal and sre hin the pst 2 wes? Mayra bang maka na may gna | | th sion allan maka ne daa 2) go?) "Tle yo ai any cnt with anyone with ever, ough, ali nd sare throat inthe pat? wes? (Meyro hr ang nats me mayan |) | tpn tat tamanon anata dane (2) bo) (Uae a yma abn Ppa 0 natalia na 14m ro) | Tr Tle you tale ide of te Pilipinas ete la 14 da? haw boy raxbyahe sa labs ne Pilipinas a nabs na ne ae?) |) | Hive you velo any aa i NCR wide iow yur one? o be napa ab pong pare ngNCKo Mer Manned 38 org hay?) Spec Sebie sa) "Have you velo yaa NCW sie om your ome? ajo now np sib pgp ng NCR Mero Mart bad song uy Spec Suna "hry aheriz [nae of exaishnent clean reese data indict ere the Selby RA 117 Dan Pay Aa 292, tT eB RA 10 Siontre: Dat hereby autor fae of sabia cob ad races thet ce hei fr tbe {2 rowete ty RA TOIT, Data Pvacy Act of 2012, and tht Ca gue 3) RA TI, Bayan Heal One Act prvi a iran Signe: Dat: