CHAS - Visitors

All PMI visitors are required to complete this questionnaire. This questionnaire hopes to assess your risk condition. The undersigned declares that the answers to the following questions are true to the best of his/her knowledge:

SUPPORT NOTE: If you are experiencing issues on this form, please contact our Information Systems Section at servicerequest@pricon.ph.

NOTE: All fields with asterisk (*) are required.

RESIDENCE: (Current home address) *

YOUR COMPANY E-MAIL: (Please enter one company e-mail address only.)*

YOUR POSITION IN THE COMPANY: *

COMPANY NAME: (The company you are currently working.) *

COMPANY ADDRESS LOCATION: *

NATURE OF VISIT: *

Official Personal

NAME PERSON TO BE VISITED IN PMI: *

POSITION OF THE PERSON TO BE VISITED IN PMI: *

E-MAIL ADDRESS OF THE PERSON TO BE VISITED IN PMI (Please enter one e-mail address only.): *

**1 - Are you experiencing the following: (Nararanasan mo ba ang mga sumusunod: )**

A. What is your current body temperature? (Ano ang kasalukuyang temperatura ng iyong katawan?) *

B. Is your body temperature over 37.5 C? (Ang iyong temperatura ba ay higit sa 37.5 C?)
(Automatically answered based on question letter A)*

Yes No

C. Sore throat (Pananakit ng lalamunan / masakit lumunok). *

Yes No

D. Cough and hard to breathe (Ubo na may kasamang hirap huminga). *

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). *

A. Close contact with health care worker or person who has exposure in caring patient with COVID-19? (May nakasama ka ba na health care worker o taong nag-aalaga na may COVID-19?) *

Yes No

B. Living in the same household as a COVID-19 patient? (May kasama sa bahay na may COVID-19?) *

Yes No

3 - Have travelled outside of the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?) *

Yes No

4 - Do you had any sickness in the past 2 weeks other than mentioned above? (Ikaw ba ay nagkaroon ng kahit anong sakit sa nakalipas na dalawang (2) linggo maliban sa nabanggit sa taas?) *

Yes No

A. Please specify what are those sickness. (Isulat kung ano ang mga sakit na iyon.)

**5 - Mode of transport in going to PMI (Ginamit o gagamitin na sasakyan papunta ng PMI)**

A1. Company / Personal Car/ Motorcycle? (Sumakay ka ba gamit ng iyong personal na sasakyan/ company car/ motorsiklo?) *

Yes No

A2. What is the Plate Number of your Company/ Personal Car/ Motorcycle? (Ano ang plate number ng iyong personal na sasakyan/ company car/ motorsiklo?)

A3. What is your appointment date and time in PMI? (Anong petsa at oras ang iyong pagpunta o pagbisita sa PMI?)

B1. Walk In? (Naglakad ka ba papunta ng PMI?) *

Yes No

B2. What is your appointment date and time in PMI? (Anong petsa at oras ang iyong pagpunta o pagbisita sa PMI?)

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.)

This is to inform you that you've answered the following questions with "YES":

DO YOU REALLY WANT TO SUBMIT THIS FORM? Click the button "YES" if you want to submit, otherwise click button "NO" to go back and change your answer(s).

PMI COVID-19 HEALTH ASSESSMENT QUESTIONNAIRE FOR VISITORS

1 - Are you experiencing the following: (Nararanasan mo ba ang mga sumusunod: )

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). *

5 - Mode of transport in going to PMI (Ginamit o gagamitin na sasakyan papunta ng PMI)

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

**1 - Are you experiencing the following: (Nararanasan mo ba ang mga sumusunod: )**

**5 - Mode of transport in going to PMI (Ginamit o gagamitin na sasakyan papunta ng PMI)**

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