Health Checklist
LASTNAME
FIRSTNAME
AGE
CONTACT NUMBER
EMAIL ADDRESS
TEMPERATURE ( To be accomplished by Guard on Duty )
PURPOSE OF VISIT
COMPANY NAME ( if applicable )
COMPANY ADDRESS
COMPANY CONTACT INFORMATION
Are you experiencing any of the following ?
YES
No
Sore Throat
Cough
Colds
Body Pains
Headache
Fever for the past few days
Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
Have you had any contact with anyone with fever, cough, colds, and sore throatin the past 2 weeks
Have you traveled outside of the Philippines in the last 14 days?
Have you traveled to any area in NCR or other regions with confirmed cases of COVID-19 aside from your home within the last 14 days?
Clear selection
If your answer to the preceding question is yes, kindly list down the areas you have visited for the past 14 days along and the respective dates you were there.
I authorize Brent International School Baguio to collect and process the data indicated herein forthe purpose of effecting control of the COVID-19 virus. I understand that my personal information is protected by RA 10173, the Data Privacy Act of 2012, and that I am required by RA 11469, the Bayanihan to Heal as One Act, to provide truthful information.
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