Full Name

Address (City Only)

Mobile Number

Email

Ministry (if any)

Purpose of entering COG

Date of entry to COG

1. In the last 2 weeks, have you experienced:

a. Fever (temperature of 37.5°C and above) YesNo
b. Sore Throat YesNo
c. Body Pains YesNo
d. Headache YesNo
e. Shortness of breath or difficulty in breathing YesNo
f. Runny nose / colds YesNo

2. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past two (2) weeks? YesNo

3. In the last two (2) weeks, have you worked together or stayed in the same close environment of a confirmed or suspected COVID-19 case? YesNo

4. Does anyone who stays in your house work as a medical or non-medical frontliner (e.g hospital staff, barangay health workers, police or military personnel, grocery worker, bank employee, food delivery crew, etc.)? YesNo