MSAS COVID-19 HEALTH DECLARATION FORM (HDF)
As we prepare to return to our workplace, we would like to request you to fill out the HDF and submit for assessment. From this form, we will classify PSC employees who will: 1. WORK ON SITE (back to PSC) and 2. WORK FROM HOME (remain at home). This way, we can help in controlling the spread of COVID-19 which is still present in our environment. We want you and your co-workers to be healthy and avoid being infected by the virus.

Your HONEST and ACCURATE responses to the items will be your contribution to the fight against COVID-19.
Be assured that your replies will be treated with confidentiality.

If you do not have an Email address - you need to create one. You will submit this HDF regularly (for health monitoring purposes) until COVID 19 is eradicated.

Thank you for your cooperation.

**We have added questions about vaccine against Covid-19 to determine the vaccination status of PSC employees***

We Heal As One!

PSC-MSAS
Email *
Did you avail your Covid 19 Vaccine? *
If Yes, what vaccine was given to you?
How many dose (s) of vaccine have you received?
Clear selection
I have done a Covid-19 test (RT-PCR) *
If Yes, give date and result (latest test)
MM
/
DD
/
YYYY
RT-PCR Test Result:
Clear selection
PERSONAL INFORMATION
Contact details are important in case of possible Contact Tracing.
Name *
Age (last birthday) *
Department *
Office Location *
Cellphone number *
ADDRESS where you reside/stay in the last 30 days (include barangay name and/or number) *
HEALTH-RELATED INFORMATION
In the last 14 days, I experienced Flu-like symptoms ("trangkaso"). *
If you answered YES, check the symptom/s you have experienced.
In the last 14 days, there was more than one (1) case who experienced the above-named symptom/s in my area of residence/barangay. *
If Yes, give the name/street of barangay where there was more than one (1) case.
In the last 14 days, I traveled to other areas aside from my place of residence/barangay. *
If Yes, Where and When you traveled outside your place of residence.
In the last 14 days, I had close contact* with person/s who came in from outside the Philippines. *(with more than 15 mins cumulative exposure) *
If Yes, when was your contact?
MM
/
DD
/
YYYY
In the last 14 days, I had close contact* with diagnosed COVID19 positive patient/s *(with more than 2 hrs. exposure) *
If Yes, When and Where was your contact with a positive COVID 19 patient?
I was diagnosed by a doctor to have chronic* medical condition/s (ex. Hypertension, Diabetes, etc.) *
If Yes, check medical condition/s that you have
For Females: I am pregnant
Clear selection
I am presently taking maintenance medication/s *
If Yes, list down name/s of your maintenance medication/s
I am undergoing dialysis *
I am undergoing chemotherapy *
I am undergoing other treatment modality *
If Yes, list other treatment modality you are undergoing
I have done a Covid-19 test (RT-PCR) *
If Yes, give date and result (latest test)
MM
/
DD
/
YYYY
RT-PCR Test Result:
Clear selection
AUTHORIZATION
I hereby authorize the Philippine Sports Commission to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 disease. I understand that my personal information is 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.

I certify that the above declarations in the Health Declaration Form are accurate and true. Your department head will decide your final disposition after evaluating your work functions and duties.

****END****


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