Contact Tracer V0.5

Employee ID:

Name: *

Phone: *

Email Address:

Address: *

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 kumpermadong may COVID-19 o coronavirus?)

yes

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

yes

4. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

yes

5. Have you travelled to any areas in NCR aside from your home? (Ikaw ba ay nagpunta sa ibang parte ng NCR o Metro Manila bukod sa iyong bahay?) Specify where if your answer is yes. (Sabihan kung saan kung ang sagot mo ay oo.)

yes

6. I am a PWD

yes

7. I am pregnant

yes

I hereby authorize Provocative Quality Apparel Philippines (PQAP) to collect and process the data indicated in this survey for the 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, that I am required by the RA 11469, Bayanihan to Heal as One Act, to provide truthful information, and that this health declaration is in the accordance with memoranda issued by various government institutions, including the Joint Memorandum Circular No. 20-04-A Series 2020 by the Department of Trade and Industry and the Department of Labor and Employment, Memorandum Circular No. 2020-004 by the Department of Tourism, and Memorandum Circular No. 2020-077 by the Deparment of the Interior and Local Government.

Links to the various government memoranda are available here.

Health Declaration Form