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HEALTH CHECKLIST
HEALTH CHECKLIST FORM
Let us work together to prevent the spread of COVID19.
As part of the government's efforts and for your protection,
please accomplish the online health checklist for contact tracing purposes.
Contact Us
Temperature Reading
Name
Sex
Male
Female
Age
Residence
Contact No.
Nature of Visit (Please check one)
Official
Personal
If official, fill in company details below:
Company Name
Company Address
Please put a checkmark on your response to each question:
Are you experiencing the following symptoms
Sore throat
Yes
No
Cough (Ubo)
Yes
No
Colds (Sipon)
Yes
No
Body Pain
Yes
No
Headache
Yes
No
Fever for the past few days
Yes
No
Have you worked together or stayed in the same close environment of a confirmed Covid-19 case?
Yes
No
Have you had any contact with anyone with fever cough, colds, and sore throat in the past two weeks?
Yes
No
Have you travelled outside of the Philippines in the last 14 days?
Yes
No
Temperature reading
I hereby authorize
LIPA QUALITY CONTROL CENTER INC.
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 11469, Bayanihan to Heal as One Act, to provide truthful information.
Date
Time
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