PARTICIPANT ASSESSMENT FORM

NOTE: This form must be completed and submitted to safetytraining@redcross.org.ph a day before the scheduled training date. Participants
who are unable to accomplish this will not be admitted to the PRC’s First Aid and BLS-CPR Training.
(Ang dokumentong ito ay kinakailangang sagutan at ipasa sa safetytraining@redcross.org.ph isang araw bago ang itinakdang araw ng
pagsasanay. Ang hindi makakatapos sa prosesong ito ay hindi papayagang makasali sa First Aid and BLS-CPR Training ng PRC.)

Full Name Age Gender

Home Address

Company Name Training Dates

(if employed)

Please answer the following questions by ticking the box below:

Yes No
1 Are you a resident of Barangay with confirmed COVID-19 cases?
(Ikaw ba ay naninirahan sa isang Barangay na may kumpirmadong kaso ng COVID-19?)
2 Have you had close contact or exposure with a confirmed case of COVID-19?
(Nagkaroon ka ba ng pagkakataong makisalamuha sa nakumpirmadong kaso ng COVID-19?)
3 Are you experiencing any of the following: (Ikaw ba ay nakararanas ng:)
Fever (Lagnat: 37.6 ℃) Temperature: _______________________
Cough (Ubo)
Cold (Sipon)
Sore Throat (Pananakit o pangangati ng lalamunan)
Headache (Pananakit ng ulo)
Diarrhea (Pagtatae)
Do you have any of the following health conditions? (Mayroon ka bang?)
Respiratory Problem (Problema sa paghinga; halimbawa: hika)
Heart Problem and Hypertension (Sakit sa puso at altapresyon)
Immunocompromised (Mahinang resistensya; diyabetes)
Pregnant (Buntis)
REMARKS:

I hereby authorize the Philippine Red Cross to collect and process my data, in effort to control COVID-19. I understand that
my data is protected by RA 10173, Data Privacy Act of 2012, and I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: Date:

Time:

FOR PRC STAFF ONLY - DO NOT SIGN ON THIS AREA

__________________________________
ASSESSED BY
Signature over PRINTED NAME

Revision 2 / October 22, 2020 1