______________________________________

Employee/Visitor Health Declaration Form Signature over printed name

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

Address/Contact Number:
Temperature: Purpose of Visit:  
Please place a check under your response.   Yes No
a. Fever    
b. cough and/or colds     Employee/Visitor Health Declaration Form
1. Are you experiencing: Full Name (Last, Given, Middle): Date :
c. Body Pains    
d. Sore throat    
2. Have you had face to face contact with a probable or Address/Contact Number:
confirmed COVID-19 case within 1 meter and for more than Temperature: Purpose of Visit:  
15 minutes for the past 14 days?     Please place a check under your response.   Yes No
3. Have you provided direct care for a patient with probable a. Fever    
or confirmed COVID-19 case without using proper personal b. cough and/or colds    
protective equipment for the past 14 days?     1. Are you experiencing:
c. Body Pains    
4. Have you travelled outside the Philippines in the last 14 d. Sore throat    
days?     2. Have you had face to face contact with a probable or
5. Have you travelled outside the current city where you confirmed COVID-19 case within 1 meter and for more than
reside?     15 minutes for the past 14 days?    
I hereby authorize Barangay Centro, to collect and process the data 3. Have you provided direct care for a patient with probable
indicated herein for the purpose of contact tracing, effecting control of or confirmed COVID-19 case without using proper personal
the COVID-19 transmission. I understand that my personal information is protective equipment for the past 14 days?    
protected by RA 10173 or the Data Privacy Act of 2012 and that this form 4. Have you travelled outside the Philippines in the last 14
will be destroyed after 30 days from the date of accomplishment, days?    
following the National Archives of the Philippines protocol. 5. Have you travelled outside the current city where you
reside?    
I hereby authorize Barangay Centro, to collect and process the data
______________________________________ indicated herein for the purpose of contact tracing, effecting control of
the COVID-19 transmission. I understand that my personal information is
Signature over printed name 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 over printed name

Employee/Visitor Health Declaration Form

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

Address/Contact Number:
Temperature: Purpose of Visit:  
Please place a check under your response.   Yes No
a. Fever    
b. cough and/or colds     Employee/Visitor Health Declaration Form
1. Are you experiencing: Full Name (Last, Given, Middle): Date :
c. Body Pains    
d. Sore throat    
2. Have you had face to face contact with a probable or Address/Contact Number:
confirmed COVID-19 case within 1 meter and for more than Temperature: Purpose of Visit:  
15 minutes for the past 14 days?     Please place a check under your response.   Yes No
3. Have you provided direct care for a patient with probable a. Fever    
or confirmed COVID-19 case without using proper personal b. cough and/or colds    
protective equipment for the past 14 days?     1. Are you experiencing:
c. Body Pains    
4. Have you travelled outside the Philippines in the last 14 d. Sore throat    
days?     2. Have you had face to face contact with a probable or
5. Have you travelled outside the current city where you confirmed COVID-19 case within 1 meter and for more than
reside?     15 minutes for the past 14 days?    
I hereby authorize Barangay Centro, to collect and process the data 3. Have you provided direct care for a patient with probable
indicated herein for the purpose of contact tracing, effecting control of or confirmed COVID-19 case without using proper personal
the COVID-19 transmission. I understand that my personal information is protective equipment for the past 14 days?    
protected by RA 10173 or the Data Privacy Act of 2012 and that this form 4. Have you travelled outside the Philippines in the last 14
will be destroyed after 30 days from the date of accomplishment, days?    
following the National Archives of the Philippines protocol. 5. Have you travelled outside the current city where you
reside?    
 I hereby authorize Barangay Centro, to collect and process the data
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 form
will be destroyed after 30 days from the date of accomplishment,
following the National Archives of the Philippines protocol.

______________________________________

Signature over printed name