All items with (*) is a required fields
1. Did you travel outside the Philippines?
2. Did you travel outside the Pampanga?
3. Did you travel outside your Municipality?
5. Have you cared for, lived with or had direct contact of suspected case of COVID-19 but not confirmed ?
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 ?
7. Have you cared for, lived with or had direct contact of confirmed case of COVID-19?
8. Have you been exposed to someone who cared for, lived with or had direct contact of confirmed case of COVID-19 ?
- Fever > 37.6C
- Cough
- Colds
- Sore Throat
- Shortness of breathing
- Flu like symptoms
- Diarrhea
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.
FJP1.632-01