Ss HEALTH DECLARATION CHECKLIST Please check 0 Employee {J student [1 Visitor Name: Temp: °c Age: Sex: Contact # Address: Office/Purpose: Time In: Please answer truthfully the following: = Yes | NO 1. Are you currently experiencing: a. Fever 'b. Cough and/or Colds c. Body Pains d. Sore Throat e. Fatigue f. Headache g. Diarrhea h. Loss of taste or smell i. Difficulty in breathing 2. Have you been in face-to-face contact with probable or confirmed COVID-19 case without using PPE for the past 14 days? 3. Have you travelled outside the current municipality where you reside in the past 14 days? If Yes, please specify L — 1 hereby authorize Holy Name University, to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 infection. | understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that 1 am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. Signature: Date: