UPLB MNH CoVID-19 Risk Assessment Form for Visitors

UPLB MNH CoVID-19 Risk Assessment Form

For visitors and other clientele
Data Privacy Notice

The UPLB Museum of Natural History (UPLB MNH) complies with Republic Act No. 10137 (Data Privacy Act of 2012) that protects the personal information of the members public. Any information gathered in this form is strictly CONFIDENTIAL and will only be used by the UPLB MNH CoVID-19 Biosafety Committee to prevent the spread of CoVID-19. By answering the UPLB MNH CoVID-19 Risk Assessment Form, you are hereby giving consent to the UPLB MNH Biosafety Committee to use your information to determine whether or not you will be given access to the offices and sections of UPLB MNH.
Do you agree to these terms?*

YesNo

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III. Infection and Transmission Risk
Based on previous assessments, I have been categorized as:*
I have had contact with the following persons in the last 14 days or more. Check which is/are applicable.*

A person with symptoms of CoVID-19 (cough, fever, etc.)A person waiting for the result of diagnostic test for CoVID-19A person with a confirmed case of CoVID-19A person advised to undergo self-quarantineNone of the above
Have you been quarantined at home or in a quarantine facility in the past 1 month?*

YesNo
Are you completely vaccinated (2 or equivalent doses of vaccination)?*
* 1 J&J/Janssen CoVID-19 vaccine is equivalent to 2 doses.
If the answer to the above is Yes, how many boosters have you gotten already?*
Upload a photo of your vaccination card here.*

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UPLB MNH CoVID-19 Risk Assessment Form