COVID-19

NAME

COMPANY

AGE

SEX

DATE

YYYY

Purpose:

In line with our commitment to protect and ensure the health and safety of our stakeholders from any

infectious disease, all incoming visitors to GNPD (and whoever may be required) are requested to answer

the following questions completely and truthfully

Instructions:

Please answer the questions below completely and send back to your respective supervisor/department

manager/GNPD incharge personnel. The information stated herein shall be treated with utmost confidentiality

Are you feeling well right now?

YesNo

Did you travel in an infected area (Barangay or Hospitals) in the last 14 days?

YesNo

Did you use any form of public transportation. (e.g. tricycle, bus, jeepney, MRT, LRT)?

YesNo

Did you use PRIVATE transportation?

YesNo

Kindly state your route below and mode of transportation for the last 14 days

YesNo

PLACE OF ORIGIN

PLACE OF DESTINATION

MODE OF TRANSPORTATION

PublicPrivate

Have you visited malls, markets, restaurants, and other public places for the last 14 days?

Yes

Specify what you visited

Have you shared the same facility, building , or event with persons who have traveled to a location where COVID 19 has been diagnosed or suspected?

Yes

Specify the facility

Have you had any of the following for the last 7 days: fever, sore throat, cough, colds, or diarrhea?

Yes

Medicines taken

Have you been in any hospital in the last 14 days?

Yes

Specify hospital

Have you accompanied someone in any of the hospitals for the last 14 days?

Yes

Specify name of hospital

Have you been exposed to a healthcare worker who is working in any health facilities?

Yes

Specify name of health facility

Thank you for filling our travel and health form

Your data has been successfully sent