UA&P Health Forms

Email

Name

Gender

Male

Female

Address

Contact No

Have you been fully vaccinated against Covid 19? (Ikaw ba ay nakakumpleto na ng bakuna para sa Covid 19?)

Yes

Temperature ^oC

Are you experiencing any of the following? Please select those that apply or None if not applicable. (Nakakaranas ka ba ng alin man sa mga sumusunod? Piliin ang naaangkop na sagot mula sa listahan.)

Sore throat (Pananakit ng lalamunan / Hirap sa paglunok)

Body pains (Pananakit ng katawan)

Headache (Pananakit ng ulo)

Loss of taste (Kawalan ng panlasa)

Loss of smell (Kawalan ng pang amoy)

Cough (Ubo)

Colds (Sipon)

Fever for the past few days (Lagnat sa mga nakalipas na mga araw)

None (Wala)

Have you worked together or stayed in the same closed environment of a confirmed COVID-19 case? (Mayroon ka bang nakasama, nakatrabaho o nakasalamuha na kumpirmadong nagkaroon ng COVID-19?)

Yes

Have you had any contact with anyone with fever, caught, colds, and sore throat, in the past two weeks? (Mayroon ka bang nakasama o nakasalamuha na may lagnat, ubo, sipon, o masakit ang lalamunan sa nakalipas ng dalawang (2) linggo?)

Yes

Have you travelled outside of the Philippines in the last 14 days? (Ikaw ba ay naglakbay sa ibang bansa sa nakalipas na dalawang (2) linggo?)

Yes

If you answered "Yes" to the above question, please specify location. (Kung "Oo" ang kasagutan sa naunang tanong, isulat ang lugar ang iyong pinuntahan)

Have you travelled to any area in NCR aside from your home? (Ikaw ba ay nagpunta sa iba pang lugar sa NCR / Metro Manila maliban sa iyong tirahan?)

Yes

If you answered "Yes" to the above question, please specify location. (Kung "Oo" ang kasagutan sa naunang tanong, isulat ang lugar ang iyong pinuntahan)

WAIVER & RELEASE
As part of academic and safety protocols for entry and physical access to the UA&P campus, its premises and services, I hereby agree to register via a QR Code prior to entry into the University premises and my availment of , University services on campus, including the UA&P Chaplaincy.

With such QR registration and being fully aware that UA&P is compliant with and fully implements the health protocols formulated and enforced by public authority:

I undertake to follow all precautionary measures enforced by University authority while inside the University premises;

I authorize the University to collect and process the data gathered 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.

I hereby waive, release, and forever discharge UA&P, its administration, personnel, and agents, on behalf of myself, my heirs, and any personal representatives, from liability or accountability for any and all damages, costs, losses or consequences of whatever nature caused upon my person or property, arising from or in connection with my authorized entry and availment of University services.

I have read and fully understand this Waiver and Release which I execute on my own free will.

I agree (Sumasang-ayon ako)

No (Hindi)

UA&P Health Declaration for Guests and Contractors UA&P Health Declaration for Guests and Contractors