Scribd
Upload
77 views1 page

Department of Education: Republic of The Philippines

This document is an employee/visitor screening questionnaire used by the Division of Cebu Province Department of Education to collect contact information and health screening responses related to COVID-19 symptoms and potential exposure. It asks questions about symptoms, contact with confirmed cases, travel history, and includes authorization to collect and process the personal data for controlling the spread of COVID-19 infection while complying with privacy laws. Respondents are required to provide truthful information as mandated by emergency measures enacted during the pandemic.

Uploaded by

GraceEstoleCalo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
77 views1 page

Department of Education: Republic of The Philippines

This document is an employee/visitor screening questionnaire used by the Division of Cebu Province Department of Education to collect contact information and health screening responses related to COVID-19 symptoms and potential exposure. It asks questions about symptoms, contact with confirmed cases, travel history, and includes authorization to collect and process the personal data for controlling the spread of COVID-19 infection while complying with privacy laws. Respondents are required to provide truthful information as mandated by emergency measures enacted during the pandemic.

Uploaded by

GraceEstoleCalo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
You are on page 1/ 1

Republic of the Philippines

Department of Education
DIVISION OF CEBU PROVINCE
Name:
EMPLOYEEE /VISITORS SCREENING QUESTIONNAIRE
(Please fill in or check the box of your answer) Temperature:

Position: Sex: Age:


Residence:
Contact Number :
Status: Teaching Personnel Non-teaching Personnel Parent Student
If Employee (Teacher/Administrator/Staff)
Division Office Personnel Section:
District/School Personnel School: District:

If Visitor: Nature of Visit: Official


Personal
If official, fill in company details below
Company Name:
Company Address:

Yes No
Sore Throat
(sakit sa tutunlan)
Are you experiencing: Body Pains
(Nakasinati ba ka og:) (sakit sa lawas)
Headache
(sakit sa ulo)
Fever for the past few days
(hilanat sa miaging mga adlaw)
Have you worked together or stayed in the same close environment of a confirmed
COVID-19 case? (nakakuyog ba kag tawo or katrabaho sa usa ka kumpirmadong
naay COVID-19/naay impeksyon sa coronavirus?)
Have you had any contact with anyone with fever, cough, colds and sore throat in
the past 2 weeks? (naa ba kay nakakuyog nga naay hilanat, ubo, sip-on ug sakit sa
tutunlan sa niaging duha ka simana?)

Have you travelled outside of the Philippines in the last 14 days? (Nakalarga baka sa
gawas sa Pilipinas sa niaging 14 ka adlaw?)

Have you travelled to any area in the Philippines aside from your home?
(naka biyahi baka sa laing lugar diri sa Pilipinas gawas sa inyong puluy-anan?)
Specify (asa man nga lugar):

I hereby authorized Department of Education, to collect and process the data indicated herein 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, and that I am required by RA 11469, Bayanihan to Heal as
One Act, to provide truthful information.

Signature Over Printed Name: Date:

You might also like