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Self Assessment / Checklist Form

This document is a self-assessment form used by the Philippine National Police to screen individuals for COVID-19 symptoms and exposure risks. It collects information about an individual's health conditions, recent travel history within the past 14 days both domestic and international, history of COVID-19 testing or exposure, and close contact with potential carriers. The form requires a signature to declare that all information provided is true and acknowledges legal penalties for falsified responses, as it is used to identify and manage infection risks.

Uploaded by

Aiza Rhea Santos
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174 views1 page

Self Assessment / Checklist Form

This document is a self-assessment form used by the Philippine National Police to screen individuals for COVID-19 symptoms and exposure risks. It collects information about an individual's health conditions, recent travel history within the past 14 days both domestic and international, history of COVID-19 testing or exposure, and close contact with potential carriers. The form requires a signature to declare that all information provided is true and acknowledges legal penalties for falsified responses, as it is used to identify and manage infection risks.

Uploaded by

Aiza Rhea Santos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

NATIONAL POLICE COMMISSION


PHILIPPINE NATIONAL POLICE
HEADQUARTERS SUPPORT SERVICE
Camp BGen Rafael T Crame, Quezon City

Self Assessment / Checklist Form


Rank/Name: Date:
Age: Sex: Unit: Mobile Number:
Home Address:

Workplace Address: Occupation (for CIV/dependents):

HEALTH CONDITION TRAVEL HISTORY HISTORY OF EXPOSURE


(Within the last 14 days) (Within the last 14 days)
Presence of the following: Specify the place/s where Have you undergone COVID-19 testing:
YES NO you’ve been the past few ____ Yes
Fever days as well as the date: If yes, Date & Result:
Cough ____ No
(productive or Have you been in close contact with a
non-productive confirmed case/s of COVID-19?
cough) ____ Yes
Shortness of If yes, Date and Result:
breath
Cold ____ No
Sore throat If with recent travel, specify Specify health care facility:
Runny nose the location and date of
Nasal your travel abroad: Have you been in close contact who
Congestion works in a healthcare facility/hospital or is
Muscle pains currently living with you?
Headache ____ Yes
Difficulty of ____ No
Breathing Specify health care facility where your
Diarrhea friend/relative works:
Loss of sense
of Smell
Recent travel in the Have you been in close contact with a
Loss of sense
Philippines: relative or friend who had been to a
of Taste
____NCR country or place with confirmed cases of
NONE
Specify: ______________ COVID-19?
_____________________ ____Yes
____Others ____ No
If identified with presence of
Specify: ______________ Specify which country and date of close
the above, since when?
_____________________ contact with relative or friend:
Date: ________________

Declaration: The information I have given herein is true, correct, and complete. I understand that failure to answer any question or
any falsified response may have serious consequences. (Article 171, & 172 of the Revised Penal code of the Philippines and RA 11332.)

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME


OF TRIAGE OFFICER/DATE SIGNED

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