OSH Health Declaration and Contact Tracing Form
Ang mga impormasyong inyong ibibigay dito ay mananatiling para lamang sa kaalaman ng OSH, OVCSA at University Health Service at gagamitin lamang, sa panahong mangangailangan ng contact tracing.
Pangalan *
Lugar na pinanggalingan (Address) *
Residence Hall
1. Sintomas
Para sa mga susunod na katanungan, piliin kung mayroon o wala, sa kasalukuyan, ng mga sumusunod sa sintomas. Siguraduhing maging tapat sa inyong kasagutan.
Ubo *
Sipon *
Lagnat *
Pagtaas ng Presyon *
Paninikip sa Dibdib/Puso *
Pagkawala ng Panlasa *
Masakit na lalamunan *
Hika *
Panghihina *
Pagtatae *
2. Contact/ Close Contact
Saan nagpunta nitong nakaraang dalawang araw? *
Ilan ang naging close contact? (Close contact: Indibidwal na nakasalamuha ng 15 o mahigit pang minuto, na mayroong 2 metro o mas maliit pa na layo, mayroon man o walang facemask/shield) *
Sino-sino ang mga naging close contact? (Lagyan ng contact number kung saan maaaring ma-inform ang iyong naging close contact) *
3. Iba pang imposmasyon:
May alam ka bang kaso ng Covid-19 sa iyong mga napuntahan? *
May alam ka bang kaso ng Covid-19 malapit sa inyong lugar *
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