Health Checklist (test)

Date *
N/A

dd-MMM-yyyy
Employee Name
N/A
Name
N/A

Required First Required Last
Gender *
N/A
City of Residence *
N/A
Check the symptoms that you are currently experiencing. *
N/A
Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? *
N/A
Have you had any contact with anyone with a fever, cough, colds, and sore throat in the past 2 weeks? *
N/A
Have you traveled outside of the Philippines in the last 14 days? *
N/A
Have you traveled to any area in NCR aside from your home? *
N/A
Temperature
N/A
I hereby authorize Booth and Partners, 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, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.
N/A

Please check to confirm agreement to the statement above. * Please check to confirm agreement to the statement above. Required
Signature *
N/A

E-Signature Field
Clear
Status
N/A
Date *
N/A

dd-MMM-yyyy

Error Occurred