2022 NEUST COVID-19 Daily Declaration Form for Employees

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Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City
HEALTH SERVICES

PURSUANT TO Republic Act 11332, YOU ARE REQUIRED TO PROVIDE TRUTHFUL
INFORMATION ABOUT YOUR HEALTH CONDITION AND POSSIBLE EXPOSURE.

ANSWER THIS FORM DAILY BEFORE GOING TO WORK.

THE RESULT OF THIS ONLINE FORM IS BEING MONITORED DAILY BY THE HEALTH SERVICES UNIT.

Updated:
JANUARY 13, 2022

Email *

First Name *

Middle Name *

Last Name *

Extension Name

Campus *

Gen. Tinio Street Campus

Sumacab Campus

San Isidro Campus

Gabaldon Campus

Atate Campus

Fort Magsaysay Campus

Talavera Off-campus

Carranglan Off-campus

San Leonardo Off-campus

Papaya Off-campus

Penaranda Off-campus

San Antonio Off-campus

Sto. Domingo Off-campus

Employment Status *

Regular

Contractual

Job Order

Employment Category *

Faculty

Non-teaching Personnel

College/Office *

Age *

Sex *

Male

Female

Complete Address -(Street, Barangay, Town/City, Province) *

Birthday (Format: MM/DD/YYYY ex. 02/14/1950) *

Mobile Number *

Person to notify in case of emergency *

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