ORANGE NAVIGATION INC.

COVID-19 SCREENING CHECKLIST FORM

Name:________________________________ Age/Sex:__________________ Civil Status:________

Present Address:_______________________________________ Contact No: ____________________

Sa lumipasna 14 naaraw, ikawba ay nagkaroon ng mgasumusunod: OO(+) Hindi(-)

1. Lagnat ( > 38 C) + -
o
2. Ubo, Sipon, pananakit ng lalamunan o hirapsapaghiga. + -
3. Sintomas ng trangkasotulad ng pananakit ng ulo, pananakit ng kalamnan at
ng kasukasuan, pagtatae o pagkawala ng panlasa o pang-amoy. + -

4. Myembro ng Pamilyananagkaroon ng Covid-19. + -

5. Naninirahan o pumuntasalugarna may naiulatnapaglaganap ng Covid-19. + -
6. Nakasalamuhangtaona galling salugarna may naiulatna Covid-19. + -
7. May sakitsaPuso, Baga, Atay at iba pang sakittulad ng Diabetes, Altapresyon,
Cancer, lupus, Rheumatoid arthritis atbp:________________________ + -

Result of Covid-19 swabbed Test: Positive; date tested ___/___/___ Negative Not Yet Tested
O O
O
Akingpinatutunayannaanglahat ng akingmgasinagutan ay totoo, tama at RA 11322: Mandatory Reporting of Notifiable Diseases and Health
kumpletosaabot ng akingkaalaman. Events of Public Health Concern Act. Section 9:Tampering of
records or intentionally providing misinformation and non-
___________________________________________________________ cooperation of persons that should report and/or respond to
LagdasaIbabaw ng Pangalan ng Pasyente/Kamamg-anak notifiable diseases or health events of public concern; is a criminal
act and punishable by law.

Vessel Name:______________________ Date:__________________________ Time:_______________________

ORANGE NAVIGATION INC.

COVID-19 SCREENING CHECKLIST FORM

Name:________________________________ Age/Sex:__________________ Civil Status:________

Present Address:_______________________________________ Contact No: ____________________

Sa lumipasna 14 naaraw, ikawba ay nagkaroon ng mgasumusunod: OO(+) Hindi(-)

1. Lagnat ( > 38 C) + -
o
2. Ubo, Sipon, pananakit ng lalamunan o hirapsapaghiga. + -
3. Sintomas ng trangkasotulad ng pananakit ng ulo, pananakit ng kalamnan at
ng kasukasuan, pagtatae o pagkawala ng panlasa o pang-amoy. + -

4. Myembro ng Pamilyananagkaroon ng Covid-19. + -

5. Naninirahan o pumuntasalugarna may naiulatnapaglaganap ng Covid-19. + -
6. Nakasalamuhangtaona galling salugarna may naiulatna Covid-19. + -
7. May sakitsaPuso, Baga, Atay at iba pang sakittulad ng Diabetes, Altapresyon,
Cancer, lupus, Rheumatoid arthritis atbp:________________________ + -

Result of Covid-19 swabbed Test: Positive; date tested ___/___/___ Negative Not Yet Tested
O O
O
Akingpinatutunayannaanglahat ng akingmgasinagutan ay totoo, tama at RA 11322: Mandatory Reporting of Notifiable Diseases and Health
kumpletosaabot ng akingkaalaman. Events of Public Health Concern Act. Section 9:Tampering of
records or intentionally providing misinformation and non-
___________________________________________________________ cooperation of persons that should report and/or respond to
LagdasaIbabaw ng Pangalan ng Pasyente/Kamamg-anak notifiable diseases or health events of public concern; is a criminal
act and punishable by law.

Vessel Name:______________________ Date:__________________________ Time:________________________