Health. Work. Life.
Screening and Survey Form
NOTE:
  1. YOUR MEDICAL HISTORY IS IMPORTANT TO US
    Intentional concealment of relevant information or refusal to cooperate by persons affected by a health event or public concern is a crime under the REPUBLIC ACT NO. 11332
  2. Please check your information before proceeding to the next page.
  3. Fields with asterisk (*) are mandatory.
  4. For succeeding clearance prior to re-entry, please fill out the Daily Health Checklist.
Basic Information
Medical History
Symptoms and Transportation
Exposure History
Others
Basic Information
Personal Information
Last Name:
First Name:
Middle Name:
Gender:
Birthday:
Civil Status:
Company:
Worksite or Clinic Branch:
Department:
Work Site or Location:
Email Address:
Employee ID or Any Valid ID Number:
Make sure to not forget your Employee or ID Number. You'll be using it in the Daily Health Questionnaire.
Medical History
Note: Please tick (done) your answer/s.

Current Medical Conditions:

Medications, if any (include dosage):
Symptoms
Note: Please tick (done) your answer/s.

1. Do you have any of these symptoms in the past 14 days?

2. What mode of transportation do you use going to work?

2.1 If you use private transportation, do you carpool or share your vehicle with others commuting to and from work?

2.1 If you use private transportation, do you carpool or share your vehicle with others commuting to and from work?

Exposure Histroy
Note: Please tick (radio_button_checked) your answer/s.

a). Did you travel in an area with local transmission of COVID-19?

a.1). If yes, when did you travel in an area with local transmission of COVID-19?
a.2). If yes, where did you travel in an area with local transmission of COVID-19?
b). Did you recently travel outside the country?

b.1). If yes, when was your last travel outside the country?
c). Did you have close contact with confirmed COVID-19 case?

c.1). If yes, when did you have contact with a confirmed COVID-19 case?
Others
Note: Please tick (radio_button_checked) your answer/s.

3. Were you advised to undergo self-quarantine?

3.1. Reason for self-quarantine?
3.2. Duration of self-quarantine (number of days)
3.3. Were you monitored by the local health office?

3.4. Please provide self-quarantine certificate issued by your barangay (if yes) or physician (if no). [PDF, WORD, PNG, JPG, JPEG]
File
4. Were you tested for SARS-CoV-2 (COVID-19)?

4.1. If yes, when were you tested?
4.2. If yes, what was the result of the test?
5. What type of test was done?

5.1. Which type of Rapid Antibody Test?

5.1. If you tested positive with RT-PCR, was a repeat test done?

5.2. If yes, when was the repeat RT-PCR test done?
5. Were other tests done?

5.1. If yes, when were the other tests done?
5.2. If yes, please specify the tests done.
6. Were you confined for COVID-19?

6.1. If yes, duration of confinement (number of days)
6.2. If yes, please provide a copy of clinical abstract or discharged summary from the hospital where you were confined. [PDF, WORD, JPG, JPEG, PNG]
File