TNPH ONLINE HEALTH DECLARATION Personal InformationEmployee Number *Date * IMPORTANT NOTICE: A copy of the form will be emailed to you, form must be presented to security personnel upon entry of TNPH premise. Email address * Health Declaration SurveyDirection: Please answer the questions below by providing honest and accurate information. Main objective of the questionnaire is to be able to provide medical advice for those who may be at risk of being exposed to Novel-Corona virus (Covid-2019). A. Do you have or feel any signs and symptoms in the last 7 days? *NoYesStart date of sickness *Select experienced symptoms *FeverShortness of breathSore throatCoughs and coldsHeadacheOthersOther symptoms * B. In the last 7 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19? *NoYes C. Have you had consultation with a doctor in the last 7 days? *NoYesDate of consultation *Doctor's findings * D. Have you been in a hospital in the last 7 days? *NoYesDate of hospital visit *Name of hospital *Reason of hospital visit *I am sickRelative or friend is sickOther reasonReason of hospital of hospital visit *Hospital findings * E. Did you travel or visit any city or country within the past 7 days *NoYesDate of travel or visit *What city or country did you visited? * F. Do you have plan to attend or had attended an event in the last 14 days *NoYesEvent date *Select the type of event *Get togetherWeddingOutingReunionConcertsMovieSeminar or conventionMeeting or conferenceGoing to mallMass gathering (holy mass, funeral, birthday, etc.)OthersOthers * G. Have you been visited or have you visited another household (relative or friend) with any sick member in the last 7 days? *NoYesDate you have met *Indicate what kind of sickness *Select type of physical contact *Close conversation (within 3 feet)Sharing of foods and utensilsHandshakingOthersOthers (copy) * H. In the last 7 days, do you have a household member who got sick? *NoYesIndicate what kind of sickness or diagnosis *When does the sickness start? * NOTE: Please secure online consultation or telemedicine consultation for your sick household member. Medical certificate must be sent through TNPH clinic e-mail: tnph_clinic@dtms.denso-ten.com I. In the last 14 days, have you been exposed to a household member who undergone swab test, antigen test or rapid test? *NoYesSpecify start date of exposure * Terms and Agreement *I hereby declare that all information given is true and correct. If found that any false information or misrepresentation made here to shall be a ground for disciplinary action based from company Code of Ethics. NameSubmit
