Scribd Logo
Upload

Welcome to Scribd!

  • 25 views

    Daily Health Checklist

    Uploaded by

    Ma. Charlene Sison
    This daily health checklist collects personal information and health status details from students, employees, guests, and their household members. By completing it, individuals agree that their personal data may be collected, used, and processed to review current health status and prevent COVID-19 infection. Personal information is protected by the Data Privacy Act of 2012. Requests to inspect, amend, or restrict records must be made in writing to the Data Privacy Office and specify reasons for the request. Miriam College reserves the right to respond appropriately according to law.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Daily Health Checklist

    Uploaded by

    Ma. Charlene Sison
    25 views2 pages
    This daily health checklist collects personal information and health status details from students, employees, guests, and their household members. By completing it, individuals agree that their personal data may be collected, used, and processed to review current health status and prevent COVID-19 infection. Personal information is protected by the Data Privacy Act of 2012. Requests to inspect, amend, or restrict records must be made in writing to the Data Privacy Office and specify reasons for the request. Miriam College reserves the right to respond appropriately according to law.

    Original Title

    DailyHealthChecklist

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This daily health checklist collects personal information and health status details from students, employees, guests, and their household members. By completing it, individuals agree that their personal data may be collected, used, and processed to review current health status and prevent COVID-19 infection. Personal information is protected by the Data Privacy Act of 2012. Requests to inspect, amend, or restrict records must be made in writing to the Data Privacy Office and specify reasons for the request. Miriam College reserves the right to respond appropriately according to law.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views2 pages

    Daily Health Checklist

    Uploaded by

    Ma. Charlene Sison
    This daily health checklist collects personal information and health status details from students, employees, guests, and their household members. By completing it, individuals agree that their personal data may be collected, used, and processed to review current health status and prevent COVID-19 infection. Personal information is protected by the Data Privacy Act of 2012. Requests to inspect, amend, or restrict records must be made in writing to the Data Privacy Office and specify reasons for the request. Miriam College reserves the right to respond appropriately according to law.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Daily Health Checklist

    Data Privacy Clause: By completing this slip, I hereby agree that Miriam College may collect, use, disclose and process
    my personal data for the purpose of reviewing current health status of all students, employees, guests and their
    household members to prevent the risk of COVID-19 infection. I also understand that my personal information is
    protected by the Data Privacy Act of 2012 and that I am required by the Bayanihan to heal as One Act to provide
    truthful information. Requests for inspection, amendment or restriction of records must be in writing and addressed to
    MC’s Data Privacy Office and must specify the reasons for the request. MC reserves the right to respond appropriately
    according to law.

    DATE: ___________________ TEMPERATURE:___________________

    PERSONAL INFORMATION
    Name: ______________________________Sex: ______Age: _______ Nationality: ___________

    Please check one: __Employee__ Student __Parent/Guardian ___Guest ____Outsourced Service Provider

    Complete Home Address: __________________________________________________________________________

    Is your barangay under extreme ECQ or in total lockdown? _____Yes _____No

    Contact Number/s (landline and mobile): ______________________________________________________________


    Please identify the person and the office of the person you are visiting:
    _____________________________________________________________________________________

    PERSONAL HEALTH STATUS

     Are you currently experiencing or have you experienced any of the ff. symptoms within the last 2 weeks? fever,
    runny nose/ cold, cough, fatigue, headache, lack of appetite, diarrhea, sore throat, tightness of the chest, loss of smell and/or
    taste, muscle pain, chills, fatigue, shortness of breath or vomiting
    _____Yes (please specify the symptom/s:_________________________________________________
    _____No
     If you are not manifesting any symptoms, were you advised to undergo self-quarantine and being monitored by your
    barangay health workers?
    _____Yes (specify the number of days to complete: ______________) _____No
     Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
    _____Yes _____No
     Have you travelled outside of the Philippines in the last 2 weeks? _____Yes _____No
     Have you travelled to any area in NCR aside from your home?
    _____Yes (please specify the city) _________________________________________
    _____No
    HEALTH STATUS OF HOUSEHOLD MEMBERS
     Is anyone in your household currently experiencing any of the symptom/s and/or have experienced any of the
    symptom/s listed above within the last 2 weeks? Yes _____ No_____
     If your household member/s is/are not manifesting any symptoms, is/are any of them undergoing self-quarantine
    and is/are being monitored by your barangay health workers?
    o Yes _____ (specify the number of days to complete: ______________) No_____

    Signature Signature of parent/guardian (for students who are minor)


    __________________. ________________________

    You might also like