CONFI
DENTI
AL
ANNEXA:COVI
D-19Ret
urnt
oWor
kHeal
thCheckQuest
ionnai
re(
RWHCQ)
Tobef
il
ledoutbyt
heEVALUATI
NGSTAFF/HEALTHCAREPROVI
DER
//CanRet
urnt
oWor
k //ForRapi
dTest
ing //ForPCRTest
ing
//ForFur
therMedi
cal
Consul
tat
ion //Ot
her
s__
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Author
izedSignatur
eOv erPri
ntedName Dat
e
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Tobef
il
ledoutbyt Pl
heEMPLOYEE( easewr
it
ecl
ear
lyi
nBl
ockl
ett
ers)
Inst
ruction:
Anempl oyeewhohasbeeni denti
fi
edasr et
urni
ngtoworkshal laccompli
sht hi
sForm.Theaccompl i
shedfor
m mustbe
submi t
tedt otherespect
iveOffi
ce’
sDesi
gnatedFluManagerandmustbesi gnedbytheSector/GroupHeadorDesignat
ed
Offi
cerpr i
ortoitssubmissiontoHRG.Pleaseatt
achaddit
ionalsheetsifnecessar
y.Alt
ernati
vel
y,anapprov
alt
hroughthe
offi
cialemailoftheSector/Gr
oupHeadorDesignatedOf
fi
cermaybesubmi tted.
Name:
(LastName,
Fir
stName,
Middl
eName) Empl
oyeeNo.
: Dat
e:
Sect
or: Gr
oup: Mobi
l
eNo.
: e-
mai
laddr
ess:
Di
vi
si
on: Depar
tment
/Br
anch:
CompleteCurr
entResidenti
alAddress:
Uni
tNo./StreetName Condomini
um Buil
dingSubdivi
sion
Barangay
Town/
Muni
cipal
i
ty
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_ _
_____
_ _
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_____
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Ci
ty Provi
nce
__
_____
_____
__
_
______
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_______
_
Pl
easecheck:
____famil
y/rel
ati
ves’
resi
dence __
_boar dinghouse/
dormi
tory
___
_condomini
um uni
t ___other
s, pleasei
ndi
cat
e__
_ _
____
___
___
___
___
__
I
fboardinghouse/dormitory,
doy ougohomet oy ourper
manent/f
amilyresidence?☐No☐Yes
Provi
decompl et
eaddr essbelow:
UniNo./St r
eetName Condomi nium Bui
ldi
ng/Subdiv
isi
on
Barangay
Town/Muni
cipal
i
ty
__
_ _
____
_ _
____ ______
_____
_____
_____
_ _
___
__
_
____
___
_____
__
__
_ __
_ __
____
____
__
Ci
ty Provi
nce
__
_ _
____
_ _
____
______
_____
_____
_____
_ _
___
__
Age: Sex
: Pr
e-exi
sti
ngI
ll
ness/
Comor
bidi
ty:
ForFemale-Ar
ey oupr
egnant
?☐No☐Yes ☐Di abetes☐Hi ghbloodpr essure☐Highcholest erol☐Stroke ☐
High-
RiskPr
egnancy☐No☐Yes Ki
dneyDi sease☐Hear tDi
sease☐Hear tpal
pitati
on ☐
Respiratoryorlungdisease☐Ast hma☐Cancer
☐Thy roiddi sease☐Obesi ty☐Lupus☐Ar thri
tis☐Hepat it
isB ☐
Li
verDi sease☐Ot hers,pl
sindicate_
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_ _
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_
Tar
getRet
urnDat
e:Cl
i
ckort
apt
oent
eradat
e. Of
fi
ceAddr
ess:
Wor
kSchedul
e:☐Mon☐Tue☐Wed☐Thu☐Fr i
☐Sat☐Sun
Wor
kHours:☐7:
00-
4:00☐7:
30-
4:30☐8:
00-
5:00☐8:
30-
5:30☐9:
00-
6:00☐9:
30-
6:30☐10:
00-
7:00☐_
:__
-__
:__
Others/
Remar ks-IfYES,pl
easepr ovi
de…
1 COVID-19 Haveyouhadanyclosecont
actwi
tha Dateofl astcontact:
Cli
ckort aptoenteradat
e.
Exposure COVID-
19Posit
ive? Presenthealthconditi
onoft heperson:
☐No
☐Conf ined☐Sel f
-Quarant
ine☐Recov ered
☐Yes
I
nthepast
14day
s
Haveyouhadanyclosecont
actwi
th Dateofl astcont
act:Cli
ckortaptoenteradat
e.
COVID-
19SuspectCase? Presenthealthcondit
ionoftheperson:
☐No
☐Conf ined☐Sel f-
Quaranti
ne☐Recov ered
☐Yes
Haveyouhadanyclosecont
actwi
tha ☐No Dateoflastcont
act:
Cli
ckortaptoenteradat
e.
COVID-
19Probabl
eCase? ☐Yes Presentheal
thcondi
ti
onoftheperson:
CONFI
DENTI
AL
☐Conf
ined☐Sel
f-
Quar
ant
ine☐Recov
ered
2 Hi
stor
yof Didyouhaveanyofthefoll
owi
ngi
n I
fYES,Il
lness/ Di
agnosi
s:
I
ll
ness thepast14daystopresent
? SubmitFittoWor k/Medical
Certi
fi
cat
e
☐No Peri
odCov eredFrom Cli
ckortapt
oenteradat
e.
☐Fever☐Cough☐Fl u/
Col
ds ☐Yes
ToCli
ckortaptoent
eradate.
☐SoreThroat☐Breathi
ngDif
fi
cul
ty
☐Dizzi
ness☐Diarrhea
☐BodyPain☐Ot hers
Inthepast14days,
havey ouhad
closecont
actwit
hanyone( i
ncl
udi
ng
yourhousehol
dmember s)with
☐No
☐Yes
☐Fev
er☐Cough☐Col
ds
☐Sor
eThr
oat
3 Tr
avel Hav ey out rav el
l
edout sidey our Bar
angay
:
Hi
stor
y residencet oabar angaywher elocal ☐No
transmi ssionofCOVI D-19hasbeen ☐Yes
Inthepast repor t
ed? Town/Municipali
ty/
Cit
y:
14day s Hav ey out rav el
l
edt oapr ov incewher e Date:Cl
ickort aptoenteradat
e.
☐No
l
ocal t
r ansmi ssi
onofCOVI D-19has Cit
y/Pr
ovince:
☐Yes
beenr epor ted?
Hav ey out rav el
l
edt oacount r
ywher e Country:
☐No
l
ocal t
r ansmi ssi
onofCOVI D-19has CountryDepar ture:
Cl i
ckort aptoenteradate.
☐Yes
beenr epor ted? PHAr ri
valDat e:Cli
ckort apt oenteradate.
4 Hospital Hav ey oubeent oahospi talorany ☐No Dateofv i
sit:Cli
ckort apt oenteradate.
Visi
t medi cal facil
ityinthepast14day s? ☐Yes Purposeofv isit
:
5 Household Doy ouhav eahousehol dmember Relati
onship:
Member s di agnosedasCOVI D-19posi ti
ve? DatesofTr eatment :From Clickortaptoentera
☐No
/Livi
ngin date.ToClickort apt oenteradat e.
☐Yes
thesame PresentHealthCondi t
ion:
house ☐Conf ined☐Sel f-
Quar anti
ne☐Recov er
ed
Doy ouhav eahousehol dmember ☐No Relati
onship:
Inthepast whoi saheal thworker/front-li
ner ? ☐Yes
14day s Doy ouhav eahousehol dmember Relat
ionshi
p:
☐No
wi t
hahi storyofdomest icorf oreign PHAr ri
valDat
e:Cl
i
ckort apt
oenteradat
e.
☐Yes
travel? From whichCi
ty/Prov
ince/
Count
ry:
Isther eaknownCOVI D-19case
wher ey ouar ecur r
entlyst aying( e.g. ☐No
subdi vision, dormitory,boar ding ☐Yes
house)
Thi
sistocert
if
ythattheaboveinformati
onprovi
dedaretrueandcorr
ecttothebestofmyknowl edge.Ialsoauthor
izePNB
tocol
l
ectandprocessthedataindicat
edheret
oforpurposeofeff
ecti
ngcontrol
oftheCOVID-19infecti
on.Iunderst
andthat
mypersonali
nfor
mationisprot
ectedbyRA10173Dat aPr iv
acyActof2012andt hatIam r
equir
edbyRA11332Mandat ory
Repor
ti
ngofNot i
fi
abl
eDiseasesandHeal t
hEventsofPubli
cHealthConcer
nActt oprovi
detr
uthf
ul i
nformati
on.
Si
gnedby:_
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Endor
sedby
/Ot
herRemar
ks:
_____
_____
_____
_____
_____
__
SignatureoftheEmployee _
_____
_____
_____
_____
_____
_
___
_____
_____
_____
_____
____
Signatur
eofSector/GroupHeador
Designat
edOff
iceroverPri
ntedName
Dat
e: _
___
___
___
___
___
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C:
\annexa–cov
id-
19r
etur
ntowor
k–heal
thcheckquest
ionnai
re
