HEALTH SERVICES UNIT
Health Checklist

𝐃𝐚𝐭𝐚 𝐏𝐫𝐢𝐯𝐚𝐜𝐲 𝐍𝐨𝐭𝐢𝐜𝐞.Information collected in this form will be used to identify personnel who are entering AIMS vicinity. Responses shall be treated as confidential in compliance with the Data Privacy Act of 2012.
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Name (Last name, First Name MI.) *
Contact Number *
Client *
Purpose of Visit *
Temperature *
Are you experiencing: (nakakaranas ka ba ng: *
Yes
No
Sore throat (pananakit ng lalamunan / masakit lumunok)
Body pain (pananakit ng katawan)
Headache (pananakit ng ulo)
Fever for the past few days (Lagnat sa nakalipas na mga araw)
Cough (Ubo)
Difficulty of breathing (hirap sa paghinga)
Have you had any contact in the past 14 days with a person who is confirmed, suspect, or probable case of COVID-19? *
I hereby authorize Asian Institute of Maritime Studies HSU, to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal informationis protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469,Bayanihan to Heal as One Act, to provide truthful information. *
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