CLUB INTRAMUROS EMPLOYEE'S HEALTH SURVEY FORM
Note: To be filled-up by employee upon arrival in the TIEZA workplace. Managers to collate the forms within the 1st day of work of the employee.
Temperature *
Email Address:
Name: *
(First Name, MI, Last Name)
Sex *
Age *
Address *
Office/Department: *
Contact Number *
HEALTH SURVEY QUESTION
1. For the past 2 weeks until now, are you experiencing: *
Required
2. Have you worked together or stayed in the same close environment with a confirmed COVID-19 case? *
3. Have you had any contact with anyone with fever, cough, colds and sore throat in the past two (2) weeks? *
4. Have you travelled outside of the Philippines in the last 14 days? *
If yes, please specify:
5. Have you travelled to any area in the Philippines in the last 14 days? *
If yes, please specify:
6. Were you hospitalized since January 2020? *
If yes, specify date and diagnosis:
*
Required
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