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    Visitore28099s Health Checklist General 2 PDF

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    Vhonek Panget
    This document is a visitor's health checklist that collects information such as name, temperature, symptoms, travel history, and recent contacts to screen for COVID-19 before entering a premises. It authorizes the collection of this health data and verifies the visitor's consent to enter voluntarily.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Visitore28099s Health Checklist General 2 PDF

    Uploaded by

    Vhonek Panget
    23 views1 page
    This document is a visitor's health checklist that collects information such as name, temperature, symptoms, travel history, and recent contacts to screen for COVID-19 before entering a premises. It authorizes the collection of this health data and verifies the visitor's consent to enter voluntarily.

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    visitore28099s-health-checklist-general-2.pdf

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    © © All Rights Reserved

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    This document is a visitor's health checklist that collects information such as name, temperature, symptoms, travel history, and recent contacts to screen for COVID-19 before entering a premises. It authorizes the collection of this health data and verifies the visitor's consent to enter voluntarily.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    23 views1 page

    Visitore28099s Health Checklist General 2 PDF

    Uploaded by

    Vhonek Panget
    This document is a visitor's health checklist that collects information such as name, temperature, symptoms, travel history, and recent contacts to screen for COVID-19 before entering a premises. It authorizes the collection of this health data and verifies the visitor's consent to enter voluntarily.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    VISITOR’S HEALTH CHECKLIST

    Date: Day: Temperature:


    Name: Time-In: Time-Out:
    Cellphone: Sex: ❑ Male ❑ Female Age:
    Home Address:
    Status: ❑ Employee ❑ Personal Visit ❑ Official Visit Company Name:
    ❑ Job Applicant ❑ Others
    Nature of Visit: ❑ Pickup/Delivery ❑ Appointment If Others, state
    ❑ Interview/Orientation ❑ Others reason here:
    Company Address:
    Please answer these questions to the following health-related questions:
    1. Are you Sore Throat? ❑ Yes ❑ No Headache ❑ Yes ❑ No
    experiencing? Body Pains? ❑ Yes ❑ No Fever for the past days ❑ Yes ❑ No
    2. Have you worked together or stayed in close environment of a confirmed COVID-19 case? ❑ Yes ❑ No
    3. Did you have any contact w/someone with fever, cough, colds, sore throat in the past 2 weeks? ❑ Yes ❑ No
    4. Have you travelled outside the Philippines in the last 14 days? ❑ Yes ❑ No
    5. Have you travelled to any area in NCR aside from your home? ❑ Yes ❑ No
    6. List the places you’ve been to today
    (For contact tracing purposes):
    By signing this document, I hereby authorize Company to collect and process the data indicated herein for the purpose of
    effecting control of the COVID-19 infection. I understand that my personal information is protected by RA 10173 (Data Privacy
    Act of 2012). I know that I am required to provide truthful information as required by RA 11469 (Bayanihan as One Act).
    I certify that as of today, I am in good health and practicing responsible social distancing. I certify that I am voluntarily entering
    the work premises out of my own free will. I will NOT hold the Company or my Agency liable if I contracted COVID-19 in its
    premises as I cannot conclusively verify that I have been infected as a result of my visit to the Company or elsewhere.
    Printed Name: Signature:

    VISITOR’S HEALTH CHECKLIST


    Date: Day: Temperature:
    Name: Time-In: Time-Out:
    Cellphone: Sex: ❑ Male ❑ Female Age:
    Home Address:
    Status: ❑ Employee ❑ Personal Visit ❑ Official Visit Company Name:
    ❑ Job Applicant ❑ Others
    Nature of Visit: ❑ Pickup/Delivery ❑ Appointment ❑ Interview/Orientation ❑ Others: ___________________
    Company Address:
    Please answer these questions to the following health-related questions:
    1. Are you Sore Throat? ❑ Yes ❑ No Headache ❑ Yes ❑ No
    experiencing? Body Pains? ❑ Yes ❑ No Fever for the past days ❑ Yes ❑ No
    2. Have you worked together or stayed in close environment of a confirmed COVID-19 case? ❑ Yes ❑ No
    3. Did you have any contact w/someone with fever, cough, colds, sore throat in the past 2 weeks? ❑ Yes ❑ No
    4. Have you travelled outside the Philippines in the last 14 days? ❑ Yes ❑ No
    5. Have you travelled to any area in NCR aside from your home? ❑ Yes ❑ No
    6. List the places you’ve been to today
    (For contact tracing purposes):
    By signing this document, I hereby authorize Company to collect and process the data indicated herein for the purpose of
    effecting control of the COVID-19 infection. I understand that my personal information is protected by RA 10173 (Data Privacy
    Act of 2012). I know that I am required to provide truthful information as required by RA 11469 (Bayanihan as One Act).
    I certify that as of today, I am in good health and practicing responsible social distancing. I certify that I am voluntarily entering
    the work premises out of my own free will. I will NOT hold the Company or my Agency liable if I contracted COVID-19 in its
    premises as I cannot conclusively verify that I have been infected as a result of my visit to the Company or elsewhere.
    Printed Name: Signature:

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