PMI COVID-19 HEALTH ASSESSMENT QUESTIONNAIRE FOR VISITORS




Official                Personal

1 - Are you experiencing the following: (Nararanasan mo ba ang mga sumusunod: )
Yes             No
Yes             No
Yes             No

2 - Worked together or stayed in the same close environment of a CONFIRMED COVID-19 case (May nakasalamuha ka ba o nakatrabahong tao na kumpirmadong may COVID-19/may impeksyon ng coronavirus). *
Yes             No
Yes             No

Yes             No

Yes             No

5 - Mode of transport in going to PMI (Ginamit o gagamitin na sasakyan papunta ng PMI)
Yes             No
Yes             No
Yes             No

I hereby authorize PRICON MICROELECTRONICS, INC. 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.



PLEASE REVIEW YOUR ANSWERS BEFORE SUBMITTING THIS FORM!
(Ugaliing suriing mabuti ang iyong mga sagot bago isumite ang form na ito.)

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