IOHSAD
Safe Workplaces Now!
COVID-19 Health Protocol Form
Pangalan*
Please enter your Name
Contact Number*
Please enter your Phone number
Full name (Kumpletong pangngalan) (Last, Given, Middle)*
Please enter your Full Name
Shift Date (Araw ng Shift):*
Please enter a Shift Date
Shift Time (Oras ng Shift: HH:MM XM):*
Please enter a Shift Time
Are you experiencing any of the following symptoms? (Nararanasan mo ba ang ilan sa mga symptoms dito?):
Fever (Lagnat)
Cough and/or Colds (Ubo at/o Sipon)
Body pains (Pananakit ng katawan)
Sore throat (Pananakit ng lalamunan/masakit lumunok)
Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1 meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na probable o kumpirmadong pasyente na may COVID-19 mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 araw)?
Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper personal protective equipment for the past 14 days? (Nag-alaga ka ba ng probable o kumpirmadong pasyente na may COVID-19 nang hindi nakasuot ng tamang personal protective equipment sa nakalipas na 14 araw?)
Have you travelled outside the Philippines in the last 14 days (Ikaw ba ay lumabas ng bansa sa nakalipas na 14 na araw)?
Have you travelled outside the current city/municipality where you reside (Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo)? If yes, specify which city/municipality you went to (Kung oo, i-type ang lungsod/munisipyong pinuntahan).
Enter your complaint here about COVID-19 protocols in your workplace.* (I-type ang inyong reklamo dito ukol sa mga protocol ukol sa COVID-19 sa iyong pinagtatrabahuhan.*)
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