EMPLOYEE HEALTH DECLARATION FORM
For the protection and safety of our families and the AEC community:
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Minutes
AM
PM
AM/PM Option
Full Name:
*
First Name
Middle Name
Last Name
Email:
*
example@example.com
Schedule:
*
Temperature:
*
Position:
*
Department/Section:
Please check if you have any of the following at present or during the past 14 days:
Fever
Body Pain
Loss of Taste or Smell
Headache
Cough
Severe Diarrhea
Sore Throat
Shortness of Breath
Other
1. Did you visit any poultry farm or animal market in the last 14 days?
*
Yes
No
1. Have you taken anti-fever medication during the last 4 to 6 hours?
*
Yes
No
2. Have you visited a hospital, clinic, or medical health facility in the past 14 days?
*
Yes
No
Name of Facility
*
Reason for Visit
*
Date of Visit
*
/
Month
/
Day
Year
Date
3. Have you attended a face to face gathering with at least 10 persons present in the past 14 days?
Yes
No
Type of Gathering
*
Date
*
/
Month
/
Day
Year
Date
Venue
*
No. of attendees
*
4. Have you been in close contact with a confirmed case of COVID-19?
Yes
No
5. Have you been in close contact with persons in quarantine/probable case of COVID-19?
Yes
No
6. Have you been tested for COVID-19 in the last 14 days?
Yes
No
Please indicate kind and result of test.
*
7. Is a household member considered a medical frontliner on active duty?
*
Yes
No
8. Does a member of your household currently have fever, cough or other symptoms associated with COVID-19?
Yes
No
9. Has a family or household member been tested for COVID-19 in the last 14 days?
*
Yes
No
Please indicate kind and result of test.
*
4. Does any household member currently have fever, cough, loss of taste/smell, and/or respiratory problems?
*
Yes
No
5. Has any household member arrived from abroad during the last 14 days?
*
Yes
No
8. In the last 14 days have you or any of your household members been in close contact with a person or patient who has displayed any symptom/s associated with COVID-19, including fever, cough, loss of taste/smell, and/or respiratory problems, regardless of whether the same person has been tested for COVID-19 or not?
*
Yes
No
10. Have you travelled outside of the Philippines in the past 14 days?
Yes
No
City and Country Visited
*
Arrival Date
*
/
Month
/
Day
Year
Date
Arrival Date:
/
Month
/
Day
Year
Date
Port of Origin:
Flight#:
Seat#:
Countries OR Local Cities visited for the past two (2) weeks:
Declaration and Data Privacy Consent Form:
The information I have given is true, correct, and complete. I understand that failure to answer any question or giving false answer can be penalized in accordance with the law or applicable company policy.I hereby give my full consent to collect, record, and process information pertaining to myself for the purpose of implementing internal protocols related to the prevention of COVID-19 in our workplace.
Signature:
*
Date
*
/
Month
/
Day
Year
*Employees are required to submit this to the HRD Office everyday, upon arrival or within one (1) hour of reporting for duty.
Submit
Should be Empty: