Health Assessment Form
Purpose: This form is exclusively for the purpose of assessing the health of an employee who will report back to work.
Full Name (Last, First MI): Age and Gender: Place of Residence:
Department/Location Position Contact No. (Employee):
Current Body temperature: Immediate Superior: Contact No. (Superior):
Do you experience any of these? Check all that apply.
Fever Body Aches Diarrhea
Sore throat Tiredness Others ___________
Cough Headache
Colds Shortness of Breath
Date and time experienced (indicate all as accurately as possible)
Have you worked together or stayed in the same close environment of a Yes
confirmed COVID 19 case? (within 500 meters radius from your No
residence)
Have you had any contact with anyone with fever, cough, colds and sore Yes
throat in the past 2 weeks? No
Have you travelled to a local destination or overseas for the past 30 No
days? Yes –
locally/Place______________________________
Yes –
abroad/Place_____________________________
How long have you been there? (indicate all durations of stay per
location. Leave blank if you answered ‘No’)
Did you have any previous disease/illness during lockdown? No
Yes
When __________________________________
Where did you get treatment? ____________________
What is the diagnosis: _____________________
Do you have the following present condition? Pregnant Cancer
Hypertension Others ________________
Diabetes
Kidney Problem
Liver Problem
I hereby authorize Bounty Fresh Food Inc., to collect and process the data indicated herein for the purpose of affecting control of
the COVID – 19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I
am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.
__________________________ __________________
Employee Name and Signature Date
Pre-Employment Checklist:
Diploma
TOR
SSS-E1 Form
Pag Ibig no. (ID or MDF or any proof)
PhilHealth no. (ID or MDR or any proof)
NBI Clearance
TIN (If fresh graduate, no need to get)
1905 (if previously employed)
Brgy. or Police Clearance
CTC (cedula) – 2 copies/ photocopy
PSA Birth Certificate - 5 copies / photocopy
Copy of vaccination card or certificate
Pre-employment Medical Certificate (with Fit-to-work result)
Valid I.D (passport, postal, driver's license, PRC) - 6 copies/ photocopy
1pc 2x2 photo, colored with white background
Certificate of Employment (if previously employed)
ITR (if previously employed)
Balances in Government Loans if there is any.
Health Assessment Form *to be fill out and submitted together with your requirements, please see attached*
Pre-Employment Checklist:
Diploma
TOR
SSS-E1 Form
Pag Ibig no. (ID or MDF or any proof)
PhilHealth no. (ID or MDR or any proof)
NBI Clearance
TIN (If fresh graduate, no need to get)
1905 (if previously employed)
Brgy. or Police Clearance
CTC (cedula) – 2 copies/ photocopy
PSA Birth Certificate - 5 copies / photocopy
Copy of vaccination card or certificate
Pre-employment Medical Certificate (with Fit-to-work result)
Valid I.D (passport, postal, driver's license, PRC) - 6 copies/ photocopy
1pc 2x2 photo, colored with white background
Certificate of Employment (if previously employed)
ITR (if previously employed)
Balances in Government Loans if there is any.
Health Assessment Form *to be fill out and submitted together with your requirements, please see attached*
