Health Declaration Form

The safety of our people remains as the top priority of Carryboy. As the outbreak of Coronavirus Disease 2019 (COVID-19) continues, it is incumbent upon all of us to remain vigilant in preventing its spread and reduce the potential risk of exposure of everyone in their workplace. Please answer this form to help us take the necessary precautionary measures to protect you and our community.

Personal Details

Name

First

Last

Age

Gender

Male

Female

Phone

Questionnaire

Temparature (°C)

**Please note that your temperature is above normal. Kindly go back to your vehicle and go straight home. Call a doctor to get further examination. Thank you**

I have visited a hospital, clinic or medical health facility in the past 14 days.

In the last 14 days and at present, I am experiencing some/all of the following: fever, colds, cough, sore throat, body pains, headache, or difficulty in breathing.

In the last 14 days, I have been in close contact with someone with fever, cough, colds, and sore throat.

In the last 14 days, I have been in close contact with a person or patient who has either (a) displayed any symptom associated with COVID-19, regardless of whether the same person has been tested for COVID-19 or not, (b) has been confirmed positive for COVID-19.

In the last 14 days, I have travelled outside of the Philippines?

I have travelled to an area outside of NCR.

None of the above.

Permission

I certify that the information I have provided is true, correct and complete. I understand that I am required to RA No. 11469 (Bayanihan to Heal as One Act) to provide truthful information, and that my failure to answer or any false/wrong information given may be a ground for the filing of appropriate cases against me under the law. I acknowledge that I have read, understood and/or have been duly informed of the terms and conditions pertaining to the data privacy practices of the Company as reflected in the Company’s Data Privacy Policy. and I hereby express my full conformity thereto.

I agree