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MetroStar Healthcheck
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Name:
Email:
Priority:
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Medium
High
Nationality:
Gender:
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Male
Female
Contact Number:
Place of Stay/Home Address:
Temperature before departing place of stay (in Celsius C):
Note:
For a Yes answer with a double asterisk (**Yes) If a certificate is not available, secure one first before proceeding to answer this form as you will not be allowed entry. When a copy is available, kindly email an electronic copy of your Gov. Health Clearance Certificate together with the health declaration form to healthcheck@myitresources.com.ph before you proceed.
Did you have COVID-19?
**Yes
No
Have you submitted an electronic copy of your Health clearance certificate to the Healthcheck officer through the healthcheck email account?
Yes
No
Have you been in contact with a confirmed COVID-19 positive case:
**Yes
No
Have you had cough, colds, runny nose, sore throat, loss of taste, hard of breathing, chills, headache, general malaise, diarrhea or have had a temperature above normal in the last 30days?
**Yes
No
Have you submitted an electronic copy of your Health clearance certificate to the Healthcheck officer through the healthcheck email account?
Yes
No
Have you travelled or arrived from any country in the past 30days?
Yes
No
If Yes, name of the country. When did you arrive? Flight transportation ID:
Have you submitted an electronic copy of your Health clearance certificate to the Healthcheck officer through the healthcheck email account?
Yes
No
Do you live with anyone or have had contact with anyone who has been sick with COVID-19 but is asymptomatic?
Yes
No
Do you live with anyone or have had contact with anyone who has cough, colds, runny nose, sore throat, loss of taste, hard of breathing, chills, headache, general malaise, diarrhea or has had a temperature above normal in the last 30days?
Yes
No
Do you live with anyone or have had contact with anyone who has transited, visited, worked, lived, in any other cities covered by a quarantine directive in the past 30 days?
Yes
No
Do you live with anyone or have had contact with anyone who has travelled, or arrived from any country in the past 30days?
Yes
No
If Yes, name of the country? When did they arrive? Flight transportation ID:
Do you live with anyone or have had contact with anyone who has been in contact with a confirmed COVID-19 positive case?
Yes
No
Do you live with anyone or have had contact with anyone who has been in contact with a COVID-19 probable case who is waiting for test results?
Yes
No
Do you live with anyone or have had contact with anyone who has attended a mass gathering, a reunion of relatives, friends or parties within the last 30days?
Yes
No
Is your barangay, place of stay covered by ECQ in the last 14 days?
Yes
No
Is your barangay, place of stay covered by MECQ in the last 14 days?
Yes
No
Is your barangay, place of stay covered by GCQ in the last 14 days?
Yes
No
Is your barangay, place of stay covered by MGCQ in the last 14 days:
Yes
No
Is your city, barangay, place of stay currently under the new normal?
Yes
No
Have you been in close contact with farm animals or exposed to wild animals in the past 14 days?
Yes
No
If yes, Describe circumstance:
Declaration:
The information I have given herein is true, correct, and complete. I understand that failure to answer any question or any falsified response may have serious consequences. (Article 171 and 172 of the Revised Penal Code of the Philippines) I voluntarily and freely consent to the collection and sharing of the above personal information only in relation to the COVID-19 internal protocols.
Please be advised that the above information shall only be used in relation to the government-mandated COVID-19 protocols and in accordance with the Data Privacy Act of ITRC/FIFASCI. This form is deemed officially signed when submitted using your official Company email.
I confirm that I have read, understand and agree
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