SUNPOWER PHILIPPINES MEDICAL

SCREENING FORM (MSF)

Please for
Disclaimer: This form will require you to share personal information read carefully
the purpose and follow
of screening the instructions
and mitigating potential COVID-19 risks.
C Information shared will be treated with utmost confidentiality and will be used only for the purpose stated.

Name: Process Group: Shift: Date Filed:

Complete Home Address: Age: Mobile#:

With COVID-19 Vaccine? ( ) No ( ) Yes - 1st Dose Date:

Vaccine Brand 2nd Dose Date:

I. SIGNS AND SYMPTOMS: Kindly put a II. MEDICAL HISTORY: (Assess for any III TRAVEL/FAMILY HISTORY /
check mark (✓) if you experience any of the RESIDENCE: Kindly put a check mark

D
co-morbidities): Kindly put a check mark
following symptoms in the last 14 days and put
(✓) if applicable and put (X) if not (✓) if applicable and put (X) if not
(X) if not

SE
( ) Fever (37.5C and above) ( ) Hypertension ( ) Travel outside the Philippines in the last 14
days

( ) Cold ( ) Cough ( ) Asthma ( ) Travel outside the current city/municipality

where you reside. If applicable, pls. specify which
city/municipality
( ) Diabetes Miletus
( ) Sore throat ( ) Body Pains
EA
( ) Close Contact with probable or confirmed
positive COVID-19 case within the last 14 days
( ) Heart Disease
( ) Diarrhea
( ) Close Contact with persons who have pending
COVID-19 test within the last 14 days
( ) Other Lung Diseases (TB, Pneumonia)
( ) Any other respiratory-related signs and
( ) Residing with family members with
EL

symptoms:_____________________
( ) Other Diseases : __________________ cough/colds/fever/sore throat/body
pains/diarrhea

Last Menstruation Period (female): Pregnant: ( ) Yes ( ) No

R

Physical Examination (to be accomplished by OH Physician): Throat: ____________ Nose: _________ Chest/Lungs: _____________

Clinic Management:

Clinic Assessment: ( ) Not Fit to Work ( ) Fit to Work

Assessed by (Clinic Personnel) : Date of Assessment:

Date of Entry or Offsite Transaction:

I hereby authorize SunPower Phil. Ltd-ROHQ to collect and process the data indicated herein for the purpose of
effecting control of 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, Bayanihan to Heal as One Act, to provide truthful information.

(Signature Over Printed Name) Date

I understand that failure to declare truthfully all relevant information may be dealt with under the Code of Discipline

I understand that failure to declare truthfully all relevant information may be dealt with under the Code of Discipline

Governing Document #: SPES-HLT-POL-53844 Page 1 of 2 Form #: SPES-ERO-FRM-63861 Rev B

 SIGNS AND SYMPTOMS: Kindly put a check mark (✓) if applicable and put (X) if not.
Date Temperature Cold Sore Cough Body Diarrhea Any other Mid-shift Signature Verified by:
Fever (37.5 throat Pains signs & Temperature
and above) symptoms Check

D
SE
EA
EL
R

Governing Document #: SPES-HLT-POL-53844 Page 2 of 2 Form #: SPES-ERO-FRM-63861 Rev B