Control No.

OED-20-05-034
HEALTH SURVEY Form No.
Version No.
MEM-OED-FM003
02
FORM Effectivity Date
Page
April 1, 2019
1 of 1

Annex A

BASIC PERSONAL INFORMATION

Full Name:
Last Name First Name Middle Name
Position: Division: Age: Sex:
Address: Mobile No.

HEALTH DECLARATION
1. Do you currently have any signs/symptoms of a respiratory infection such as the following:

Fever Cough Shortness of breath Body aches Sore throat

2. Have you had any signs/symptoms of the following in the last 14 days:

Fever Cough Shortness of breath Body aches Sore throat

3. Have you come in close contact (within 6 feet) with someone who has a laboratory
confirmed COVID-19 diagnosis in the last 14 days?

Yes No

4. Are you currently taking any medication for the following illnesses?

Hypertension Diabetes Pneumonia Obesity

Declaration and Data Privacy Consent Form

This is to certify that the information I have given is true, correct, and complete. I understand
that giving false answer can be penalized in accordance with law. I voluntarily and freely
consent to the collection and sharing of the above personal information only in relation to the
POPCOM COVID-19 internal protocols.

_________________________________ Date: ______________

Name and Signature

Please be advised that the above information shall only be used in relation to the POPCOM COVID-
19 internal protocols in accordance with the Data Privacy Act. No personal information shall be
issued to unauthorized personnel without your expressed consent.

This document is UNCONTROLLED unless stamped with “CONTROLLED”