Heaith Declaration On Covid - 19: Sources: Doh Aprii 7, 2020 Covid Aigo「Ithm

HeaIth Declaration on COVID_19
K血dIγ enCircle your answer honestly:
Failure to answer this fo「m honestiy is conside「ed a violation to the Companγ’s code on Empioyee
Discip間e, Particularly SEぐnON 3: WORK SAF馴Y AND H馴山TH
3.2 Occupationa川ealth
3.2.4 mten擁om聞y not rapo融ng hovhog o contogfous施eease肋qf can endonger rhe heo肋Qf
O勅er emphy鈍s. PIease take note that this is a Serious to G「ave offe鵬e.
1. Fever with cough or fever with sore throat for the last 14 days Yes∴∴⑥
(Meron ko bong佃gm青筋moy ubo o佃gnc軌o moy pommk;r ng h佃munon so
mkα調のng hu柄置gエ4仰o仰w?)
2. Fever, COugh. colds. sore th「oat, Or Other any respiratory signs & symptoms Yes 曲
for the Iast 14 days
仙佃仰n ko bαng hgnくけubq, S巾O旬POmn。kit "g h佃munon o姐o pong problemo sα
pagh初go償k伽w佃d m smtomas so mka仰ong hu励g J4 m or。W?)

3. 60y/o or above, With co-mOrbidity. high risk pregnancγ, heaith worker Yes ぬ
(伽w bo oy eddd 60 po調a$ mOy jb叩ang糊筋o kammdom叩, mOy de樵odong

pogbubun鵬O mOnggogOWa SO ka/usugan)
4. No signs & sγmPtOmS nOted in number l & 2 amongst γOu「 household members Yes∴屯
for the last 14 days
(肋Iong s伽omos仰m舶厄的如/ad ng朋s。刑me′O l & 2 so mgo加somong

noko飾り的bohoy s○ nok寄畑のng hu肋gエ4 m ○調所)
5. Trave冊story with no expianat!on of symptoms for the last 14 daγS Yes ㊥
(Me性)n ko bong応to明ng pog伽k。boy m my mgo sintomas m肋di mojpoliwanog

SO mkα月頃Ong huI加gエ4 m ○的Wり
6. Contact w軸probabIe case or (+) COVID 19 patient Yes 雨b
(Mem ko加ng nckoso佃muho m叩y pos硯伽d m kaso o posi肋ong kaso ng

CO間Dエ9?)
Yes 駁)
7. Fever w軸cough′ W軸n last lO days that req両「es hospitaIization
(Meron ko加ng hgno章的my ”bo sロmk伽的ng hu/ing jO αrOW m柄o妬ifongong

ma○○Sp肋I〃
Di SPOSITION/ DIAG N OSi Sこ
Va胴ated bγ: /Cbmp寄ny Phys胸on)
」ose Angeio Tayior, MD, DPCOM Ma「gauxVenus D. CuI MD DPCOM
sources: DOH Aprii 7, 2020 COVID aigo「ithm;
B○○7 手ダ均//・戸研一ろ′∴ユケ
Health Deciara舶on on COVID-19
posき章盲〇億: S凸p宮中Vめた
Department: ZAK軸一握床材
Kindly encircie you「 answer honestIy:
Failure to answe「 this form honestly is considered a vioIation to the Company’s code on EmpIoyee
Discipline, ParticuIariγ SECTION 3: WO馴K SAF馴Y AND HEALTH
3.2 Occupational HeaIth

3.2.4 /ntg〃的no勅y no書n坤ort加g hov初g o co加ogねus接eeasc thot can endonger rhe hea勅〆
o勅er emp佃yses. PIease tal(e nOte that this is a Serious to G「ave offense.
1. Fever with cough or feve「 with sore throat fo「 the last 14 days Yes ㊥
(Meron ko bmg /。gmtm mOy ubo o hgmt m maypamm柄r ng h/amumn so
nα加調ong hulh事gエ4 m O仰W?I
2. Fever, COugh, COlds. sore th「oat, Or Other any respiratorγ Signs & symptoms Yes ㊥
fo「 the Iast 14 daγS
個き仰n妬加ng佃gn旬ubq,坤0句Pomnckit ng h佃munon o触e印ng pmb佃mo sα

pog肋go伽妃tu佃d m s柵omos so mkunong柄Img 14 m o調W?)
3. 60y/0 0r above. with co-mOrbiditγ, high risk pl.egnanCy, hea軸worke「 Yes ㊥
〃同w bo oy edad 60 p同oo5, my伽pong sa妬o k伽omdom叩, my de倣αdong
pogbubun的o monggogowo so ko/usugm)
4, No signs & sγmPtOmS nOted in number l & 2 among§t yOur househoId membe「s Yes ㊨
for the last 14 daγS
(肋佃ng s伽OmaS仰m肋/。 m rubd ng mso個mero雄2 sa mgo kosamng

nokoti仰so bohoy sa m擁e脚伽g hu/mg “仰omw?)
5, Travel history w軸no expIanatIon of sγmptOmS for the last 14 days
Yes ㊥
(Meron ko bong j如or)仰ng POg伽如boy m my mgo s伽omos m h棚mojpα/iwamg
so mkα月田のng九uI肋g j4 m 0調Wり
6. Contact with probable case or (+) COVID 19 patient Yes ⑮

個eron加bang mka脚h刑hのm mqy posjb/伽d m kaso o pos舶ong kaso "g
COWDエ9り
7. Feve「 w軸cough. within last lO days that 「equires hospitalization
Yes ㊧
(Meron ko bong fogmt仰my ubo so mka朋ng hu/的1O o仰w ”O柄o剛Ongang

mローOSp舶I 〃
DI SPOSITION/DIAG N OSI S:
Validated by: /Cbmpony Phys胸cm)
」ose Angeio TaYIor, MD, DPCOM MargauxVenus D. Cu′ MD DPCOM
sources: DOH Apri1 7, 2020 COVID algo「ithm;
丁旬昨ろb.臼○○∴∴ア/初日二、割も初

Heaith Declaration On Covid - 19: Sources: Doh Aprii 7, 2020 Covid Aigo「Ithm

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Heaith Declaration On Covid - 19: Sources: Doh Aprii 7, 2020 Covid Aigo「Ithm

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HeaIth Declaration on COVID_19

K血dIγ enCircle your answer honestly:

Discip間e, Particularly SEぐnON 3: WORK SAF馴Y AND H馴山TH

pagh初go償k伽w佃d m smtomas so mka仰ong hu励g J4 m or。W?)

(伽w bo oy eddd 60 po調a$ mOy jb叩ang糊筋o kammdom叩, mOy de樵odong

(肋Iong s伽omos仰m舶厄的如/ad ng朋s。刑me′O l & 2 so mgo加somong

(Me性)n ko bong応to明ng pog伽k。boy m my mgo sintomas m肋di mojpoliwanog

6. Contact w軸probabIe case or (+) COVID 19 patient Yes 雨b

(Mem ko加ng nckoso佃muho m叩y pos硯伽d m kaso o posi肋ong kaso ng

(Meron ko加ng hgno章的my ”bo sロmk伽的ng hu/ing jO αrOW m柄o妬ifongong

Di SPOSITION/ DIAG N OSi Sこ

Va胴ated bγ: /Cbmp寄ny Phys胸on)

」ose Angeio Tayior, MD, DPCOM Ma「gauxVenus D. CuI MD DPCOM

sources: DOH Aprii 7, 2020 COVID aigo「ithm;

Kindly encircie you「 answer honestIy:

Discipline, ParticuIariγ SECTION 3: WO馴K SAF馴Y AND HEALTH

3.2 Occupational HeaIth

個き仰n妬加ng佃gn旬ubq,坤0句Pomnckit ng h佃munon o触e印ng pmb佃mo sα

(肋佃ng s伽OmaS仰m肋/。 m rubd ng mso個mero雄2 sa mgo kosamng

6. Contact with probable case or (+) COVID 19 patient Yes ⑮

(Meron ko bong fogmt仰my ubo so mka朋ng hu/的1O o仰w ”O柄o剛Ongang

Validated by: /Cbmpony Phys胸cm)

」ose Angeio TaYIor, MD, DPCOM MargauxVenus D. Cu′ MD DPCOM

sources: DOH Apri1 7, 2020 COVID algo「ithm;

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