SECURITIES AND EXCHANGE COMMISSION
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Name of Visitor
Let the visitor in
Temperature
2024-04-19
Date of Visit
12:37:13 PM
Time of Visit
Health Condition:
Sore throat
(pananakit ng lalamunan / masakit lumunok)
No
Body pains
(pananakit ng katawan)
No
Headache
(pananakit ng ulo)
No
Fever For The Past Few Days
( Lagnat Sa Nakalipas Na Mga Araw)
No
Have You Worked Together Or Stayed In The Same Close Environment Of A Confirmed Covid 19 Case?
( May Nakasama Ka Ba O Nakatrabahong Tao Na Kumpirmadong May Covid 19?)
No
Have You Had Any Contact With Anyone With Fever, Cough, Colds, And Sore Throat In The Past 2 Weeks?
( Mayroon Ka Bang Nakasama Na May Lagnat, Ubo, Sipon O Masakit Ang Lalamunan Sa Nakalipas Ng Dalawang (2) Linggo?)
No
Have You Travelled Outside Of The Philippines In The Last 14 Days?
( Ikaw Ba Ay Nagbyahe Sa Labas Ng Pilipinas Sa Nakalipas Na 14 Na Araw?)
No
Body Temperature
Are you visiting for official purposes?
- Choose Nature of Visit -
Personal
Official
Person To Visit
Company Name
Company Address
Personal Information
Lastname
Firstname
Middle Initial
Contact No
Email Address
Sex
Residence
Address
Please Inlcude Province, City/Municipality and Barangay
Questionaire
1. Are you presently experiencing
(nakakaranas ka ba ngayon ng mga sumusunod)
:
a. Sore throat (pananakit ng lalamunan / masakit lumunok)
b. Body pains (pananakit ng katawan)
c .Headache (pananakit ng ulo)
e. Loss of smell or taste (kawalan ng pang-amoy o panlasa)
f. Colds (sipon)
g. Diarrhea (pagtatae)
h. Red eyes (namumula ang mata)
d. Fever for the past few days
(Lagnat sa nakalipas na mga araw)
- Please Select -
Yes
No
2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
(May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19?)
- Please Select -
Yes
No
3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o masakit ang lalamunan sa nakalipas ng dalawang (2) linggo?)
- Please Select -
Yes
No
4. Have you stayed or resided in areas under Alert Level 5 or Enhanced Community Quarantine in the past 14 days?
((Ikaw ba ay nanatili o naninirihan sa lugar na nasa ilalim ng Alert Level 5 or Enhanced Community Quarantine sa nakalipas na 14 na araw?)
- Please Select -
Yes
No
5. Have you travelled outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
- Please Select -
Yes
No
Trace
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