UA&P Health Forms

Email

Name

Unit

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

Yes (Please present your proof of vaccination upon entry or upload a copy of your vaccination card or VaxCert here if you have not done so yet)

No (You will need to present a negative RT-PCR test result with a validity of 14 days to be able to render onsite work)

Temperature ^oC

Have you worked together or stayed in the same closed environment of a confirmed COVID-19 case in the last 14 days? (Mayroon ka bang nakasama, nakatrabaho o nakasalamuha na kumpirmadong nagkaroon ng COVID-19 sa nakaraang 14 na araw?)

Yes (Oo)

No (Hindi)

Consent and Agreement
I undertake to follow all health protocols and precautionary measures enforced by University authorities 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 agree (Sumasang-ayon ako)

I do not agree (Hindi ako sumasang-ayon)

UA&P Health Declaration Form for Employees UA&P Health Declaration Form for Employees