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    Health Declaration Form

    Uploaded by

    DOMINIC HAWANG
    This document is an employee-visitor health declaration form that collects information such as name, temperature, reason for visit, contact details, and answers to health-related questions. The questions screen for COVID-19 exposure and symptoms, including whether the person has had contact with confirmed or potentially exposed individuals, traveled outside the country or to high-risk areas, attended mass gatherings, and whether anyone in their household is currently ill. The declarant must certify that the information provided is true and may face disciplinary action for failure to disclose or providing false information.

    Copyright:

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

    Health Declaration Form

    Uploaded by

    DOMINIC HAWANG
    41 views4 pages
    This document is an employee-visitor health declaration form that collects information such as name, temperature, reason for visit, contact details, and answers to health-related questions. The questions screen for COVID-19 exposure and symptoms, including whether the person has had contact with confirmed or potentially exposed individuals, traveled outside the country or to high-risk areas, attended mass gatherings, and whether anyone in their household is currently ill. The declarant must certify that the information provided is true and may face disciplinary action for failure to disclose or providing false information.

    Original Description:

    Fit to Work Form

    Original Title

    HEALTH DECLARATION FORM_

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    © © All Rights Reserved

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    This document is an employee-visitor health declaration form that collects information such as name, temperature, reason for visit, contact details, and answers to health-related questions. The questions screen for COVID-19 exposure and symptoms, including whether the person has had contact with confirmed or potentially exposed individuals, traveled outside the country or to high-risk areas, attended mass gatherings, and whether anyone in their household is currently ill. The declarant must certify that the information provided is true and may face disciplinary action for failure to disclose or providing false information.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    41 views4 pages

    Health Declaration Form

    Uploaded by

    DOMINIC HAWANG
    This document is an employee-visitor health declaration form that collects information such as name, temperature, reason for visit, contact details, and answers to health-related questions. The questions screen for COVID-19 exposure and symptoms, including whether the person has had contact with confirmed or potentially exposed individuals, traveled outside the country or to high-risk areas, attended mass gatherings, and whether anyone in their household is currently ill. The declarant must certify that the information provided is true and may face disciplinary action for failure to disclose or providing false information.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 4

    EMPLOYEE-VISITOR'S HEALTH DECLARATION FORM

    COMPLETE NAME:
    DATE: DAY:
    TEMPERATURE: TIME IN: TIME OUT:
    CELLPHONE: GENDER: AGE:
    EMPLOYEE PERSONAL VISIT OTHERS COMPANY NAME:
    STATUS
    JOB APPLICANT OFFICIAL VISIT
    OTHERS
    WORK INTERVIEW/ORIENTATION
    NATURE OF VISIT
    APPOINTMENT PICK UP/DELIVERY
    COMPANY ADDRESS
    HOME ADDRESS
    PLEASE ANSWER THE FOLLOWING HEALTH-RELATED QUESTIONS.
    1. ARE YOU EXPERINCING ANY OF THE SORE THROAT HEADACHE
    FOLLOWING. PLEASE CHECK. BODY PAINS FEVER FOR THE PAST FEW DAYS
    2. HAVE YOU BEEN IN CONTACT OR STAYED IN A CLOSED ENVIRONEMENT WITH A PERSON POTENTAILLY
    EXPOSED TO COVID-19 AND/OR CONFIRMED COVID-19 PERSON, OR ANYONE RELATED OR HAD CONTACT WITH
    A CONFIRMED COVID-19 PATIENT? (FRIEND, RELATIVE, NEIGHBOR, COLLEAGUE)

    3. DID YOU HAVE ANY CONTACT WITH SOMEONE WITH FEVER, COUGH, COLDS, SORE THROAT IN THE PAST 3
    WEEKS?
    4. HAVE YOU TRAVELLED OUTSIDE THE PHILIPPINES THE PAST 14 DAYS?
    5. HAVE YOU TRAVELLED TO ANY AREA IN NCR ASIDE FRO YOUR HOME IN THE LAST 14 DAYS?
    6. LIST THE PLACES YOU'VE BEEN TO YESTERDAY. (FOR CONTACT
    TRACING PURPOSES)
    ADDITIONAL SAFETY AND HEALTH CHECKLIST
    1. HOW MANY ARE YOU IN THE HOUSE?
    2. IS THERE ANYONE CURRENTLY ILL IN THE HOUSEHOLD? YES NO
    IF YES, WHAT ARE THE SYMPTOMS?
    3. HOW LONG HAS THE SYMPTOM EXISTED?
    4. HAS A MEDICAL WORKER/DOCTOR EXAMINED THE PATIENT? YES NO
    5. CAN YOU GIVE AN OVERVIEW OF THE EXAMINATION RESULT?
    6. DO YOU MANIFEST ANY OF THE FOLLOWING SYMPTOMS. PLEASE CHECK.
    FEVER
    DRY COUGH
    HEADACHE
    HEAD OR MUSCLE ACHE
    SORE THROAT
    NEW LOSS OF TASTE OF SMELL
    CHILLS
    NAUSEA, DIARRHEA, VOMITING
    DIFFICULTY BREATHING OR SHORTNESS OF BREATH
    7. HAVE YOU ATTENDED A MASS GATHERING/MEETING IN THE LAST 14 DAYS? YES
    IF YES, WHERE AND WHEN?
    8. DID ANYONE FROM YOUR HOUSEHOLD ATTEND A MASS GATHERING/MEETING IN THE PAST 14 DAYS
    IF YES, WHERE AND WHEN?
    DECLARATION: I hereby certify that the above information is true and complete. I understand that my failure to answer, or a
    information given by me may be used as a ground for disciplinary action.

    ______________________________________
    Signature over printed name and Date
    DECLARATION: I hereby certify that the above information is true and complete. I understand that my failure to answer, or a
    information given by me may be used as a ground for disciplinary action.

    ______________________________________
    Signature over printed name and Date
    IF OTHERS, STATE THE REASON HERE:

    FEW DAYS

    YES NO

    YES NO

    YES NO
    YES NO

    NO

    YES NO

    my failure to answer, or any false or misleading

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