Daily Health Declaration Form Valid for one day only Name Instructions: Fill this out in the morning every day. You must provide TRUTHFUL information about your health condition and possible exposure. Any falsification is PUNISHABLE with one to six months IMPRISONMENT and a 20,000 to 50,000 FINE (Republic Act 11332). Full Name * Date Accomplished * Instruction: Please tick the appropriate response if YES or NO EXPOSURE WITHIN THE PAST 14 DAYS (from date of visit) Did you have any international or local travel or are you residing in a place with reported increase of COVID- 19 cases within the past 14 days? * Yes No Did you have any direct exposure (within 2 meters and for more than 15 minutes without wearing medical mask/N95 respirator) with a person positive for COVID-19? * Yes No Do you have a pending COVID-19 test result (RT-PCR or Rapid Antibody Test)? * Yes No Have you been tested positive for COVID-19? * Yes No SIGNS AND SYMPTOMS (during the date of visit) Did you have any of the following signs and symptoms? If you have ONE or more of the symptoms below, do NOT report for work at CARD. Mask yourself, distance yourself from others and seek medical consult. YES, Fever of more than 38°C YES, Cough YES, Colds YES, Sore throat YES, Difficulty of breathing YES, Shortness of breath YES, Influenza-like symptoms (headache, muscle and joint pains, lack of smell or taste
