Daily Health Checklist

IMPORTANT!

In compliance with the direction of The Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF), RESOLUTION NO. 149 s. 2021, dated November 18, 2021, all employees who are tasked to do on-site work must be fully vaccinated with the COVID-19 vaccine. Otherwise, they shall be denied entry, unless they present a COVID-19 RT-PCR test with a negative result done within the last 72hrs.

Classification * REQUIRED

Name (Last Name, First Name, Middle Initial) * REQUIRED

Office / Department * REQUIRED

Contact Number * REQUIRED

Email * REQUIRED

Address * REQUIRED

Are you experiencing:

Conforme * REQUIRED

I hereby authorize Mapúa University to collect and process the data indicated herein for the purpose of effecting control of COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2017, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. I also understand that failure to accomplish this form is considered non-compliance to company rules/directives and may be subject to disciplinary actions INCLUDING TERMINATION OF EMPLOYMENT.

Sore Throat? * REQUIRED	YesNo

Headache? * REQUIRED	YesNo

Cough or Colds? * REQUIRED	YesNo

Diarrhea? * REQUIRED	YesNo

Body Aches or Pains (joint pain, muscle pain)? * REQUIRED	YesNo

Fever today or past few days? * REQUIRED	YesNo

Have you been exposed to or in close contact with a confirmed COVID 19 case in the last 7days? * REQUIRED	YesNo