VISITOR’S HEALTH CHECKLIST
Date: Day: Temperature:
Name: Time-In: Time-Out:
Cellphone: Sex: ❑ Male ❑ Female Age:
Home Address:
Status: ❑ Employee ❑ Personal Visit ❑ Official Visit Company Name:
❑ Job Applicant ❑ Others
Nature of Visit: ❑ Pickup/Delivery ❑ Appointment If Others, state
❑ Interview/Orientation ❑ Others reason here:
Company Address:
Please answer these questions to the following health-related questions:
1. Are you Sore Throat? ❑ Yes ❑ No Headache ❑ Yes ❑ No
experiencing? Body Pains? ❑ Yes ❑ No Fever for the past days ❑ Yes ❑ No
2. Have you worked together or stayed in close environment of a confirmed COVID-19 case? ❑ Yes ❑ No
3. Did you have any contact w/someone with fever, cough, colds, sore throat in the past 2 weeks? ❑ Yes ❑ No
4. Have you travelled outside the Philippines in the last 14 days? ❑ Yes ❑ No
5. Have you travelled to any area in NCR aside from your home? ❑ Yes ❑ No
6. List the places you’ve been to today
(For contact tracing purposes):
By signing this document, I hereby authorize Company 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 RA 10173 (Data Privacy
Act of 2012). I know that I am required to provide truthful information as required by RA 11469 (Bayanihan as One Act).
I certify that as of today, I am in good health and practicing responsible social distancing. I certify that I am voluntarily entering
the work premises out of my own free will. I will NOT hold the Company or my Agency liable if I contracted COVID-19 in its
premises as I cannot conclusively verify that I have been infected as a result of my visit to the Company or elsewhere.
Printed Name: Signature:
VISITOR’S HEALTH CHECKLIST
Date: Day: Temperature:
Name: Time-In: Time-Out:
Cellphone: Sex: ❑ Male ❑ Female Age:
Home Address:
Status: ❑ Employee ❑ Personal Visit ❑ Official Visit Company Name:
❑ Job Applicant ❑ Others
Nature of Visit: ❑ Pickup/Delivery ❑ Appointment ❑ Interview/Orientation ❑ Others: ___________________
Company Address:
Please answer these questions to the following health-related questions:
1. Are you Sore Throat? ❑ Yes ❑ No Headache ❑ Yes ❑ No
experiencing? Body Pains? ❑ Yes ❑ No Fever for the past days ❑ Yes ❑ No
2. Have you worked together or stayed in close environment of a confirmed COVID-19 case? ❑ Yes ❑ No
3. Did you have any contact w/someone with fever, cough, colds, sore throat in the past 2 weeks? ❑ Yes ❑ No
4. Have you travelled outside the Philippines in the last 14 days? ❑ Yes ❑ No
5. Have you travelled to any area in NCR aside from your home? ❑ Yes ❑ No
6. List the places you’ve been to today
(For contact tracing purposes):
By signing this document, I hereby authorize Company 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 RA 10173 (Data Privacy
Act of 2012). I know that I am required to provide truthful information as required by RA 11469 (Bayanihan as One Act).
I certify that as of today, I am in good health and practicing responsible social distancing. I certify that I am voluntarily entering
the work premises out of my own free will. I will NOT hold the Company or my Agency liable if I contracted COVID-19 in its
premises as I cannot conclusively verify that I have been infected as a result of my visit to the Company or elsewhere.
Printed Name: Signature:
