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Employee returning to work assessment form

Personel Information

All items with (*) is a required fields

Criteria


1. Did you travel outside the Philippines?

Yes
No

2. Did you travel outside the Pampanga?

Yes
No

3. Did you travel outside your Municipality?

Yes
No

4. During ECQ?

5. Have you cared for, lived with or had direct contact of
suspected case of COVID-19 but not confirmed ?

Yes
No

6. Have you been exposed to someone who cared for, lived
with or had direct contact of suspected case of COVID-19
but not confirmed ?

Yes
No

7. Have you cared for, lived with or had direct contact of
confirmed case of COVID-19?

Yes
No

8. Have you been exposed to someone who cared for, lived
with or had direct contact of confirmed case of COVID-19 ?

Yes
No

9. CLINIC CRITERIA: Did you have the following
symptoms within the past 14 days?

- Fever > 37.6C

Yes
No

- Cough

Yes
No

- Colds

Yes
No

- Sore Throat

Yes
No

- Shortness of breathing

Yes
No

- Flu like symptoms

Yes
No

- Diarrhea

Yes
No

I hereby certify that all information stated herein are complete, true and correct according to the best of my knowledge. I have not omitted nor withheld any information requested herein, thus, any false information I indicated here will subject me to terminate my employment for a cause.


I Agree

FJP1.632-01