HEALTH CHECKLIST All employees and visitors shall accomplish the visitor’s checklist Health Checklist. Please enable JavaScript in your browser to complete this form.Access *EntranceExitEmployee & Visitor Details *FirstLastSex, Age & Temperature *FirstMiddleLastResidence: *Email AddressEmailConfirm EmailNature of Visit: *OfficialPersonalCompany Details: *Single Line Text *1. Are you experiencing: (nakakaras ka ba ng?) A. Sore Throat (pananakit ng lalamunan / masakit lumunok) *YesNoB. Body Pains (pananakit ng katawan) *YesNoC. Headache (pananakit ng ulo) *YesNoD. Fever for the past few days (lagnat sa nakalipas na mga araw) *YesNo2. Have you worked together or stayed in the same close environment of confirmed COVID-19 case? (May nakasama ka o nakatrabahong na kumpirmadong may COVID-19 / May impeksyon ng coronavirus?) *YesNo3. 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 sakit ng lalamunan sa nakalipas ng dalawang (2) lingo?) *YesNo4. Have you travelled outside of the Philippines in the las 14 days? (Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?) *YesNo5. Have you travelled to any area in NCR aside from your home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong bahay?) *YesNoSpecifyUpon Signing up, I hereby authorize Federated Distributors, 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 R.A. 10173, Data Privacy Act of 2012, and that I am required by R.A. 11467 Bayanihan to Heal as One Act. to provide truthful information.Submit
