gjtest

• Inspection no
  Address

• 1. All clients, applicants, and patients shall accomplish this form and must present the same to the Screening Officer upon entering the premises.

• 2. The screening shall consist of a temperature check and an assessment of the Covid-19 Daily Health Check Questionnaire

• 3. A client, applicant, or patient who has a temperature of below 37.5 degrees Celsius and whose Questionnaire requires no further evaluation shall be allowed to enter the premises. The Questionnaire shall be collected.

• 4. A client, applicant, or patient who has a temperature of 37.5. degrees Celsius and above and/or whose Questionnaire requires further evaluation shall not be allowed entry, and shall be advised to seek further tests or endorsed to a Covid facility. The Questionnaire shall be collected

• 5. Properly segregated collected Questionnaires (i.e. not allowed and allowed to enter) shall be collated and turned over to the NHS Aux Assistant Medical Director at the end of every work day.

Name: (Last Name, First Name, Middle Name)

• Last name:

• First name:

• Middle Name:

• Mobile No.:

• E-mail address:

  Select

• Complete Current Residential Address:

• Temperature:

• Date:

  Date

• Yes

• Yes

• Yes

Are you experiencing: (nakakaranas ka ba ng:)

• Sore throat (pananakit ng lalamunan / masakit lumunok)

  Yes

• Headache (pananakit ng ulo)

  Yes

• Body pains (pananakit ng katawan)

  Yes

• Fever for the past few days

  Yes

• 2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)

  Yes

• 3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2) lingo?)

  Yes

• 4. Have you travelled outside of the Philippines in the last 14 days?<br>(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

  Yes

• 5. Have you travelled to any area in NCR aside from your home?<br>(Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong bahay?)

  Yes

• Specify (Sabihin kung saan):

• This is to certify that the above information provided are true and correct to the best of my knowledge. I also authorize NHS Aux / NHS Inc to collect and process the data indicated hereto for 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, and that I am required by RA 11332 Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act to provide truthful information.

  Sign

• Test 1

• Test 2

• Test 3

• Test 4

• Test 5

• Calculated answer

• Who is answering this inspection?

  Mark

  Jack

  John

  Sarah

• Yes