STUDENTHEALTHASSESSMENTFORM

GABRI
ELG,
VILLEGAS CAMPUS Q.
C TEMPERATURE°
C
NAME

GENDER M
AGE 09457800860 POS STUDENT
I
TION NURSI
NG
22 CONTACTNOS. COLLEGE/
DEPT

Markahanng(✓)angsagotsamgasumusunodnakat anungan. YES NO

1.
Hav eyouexper
iencedanyoft hefol
lowi
nginthepast14days(nakar
anaskabangsumusunod
sal
oob
ngnakali
pasnalabing- 14)naar
apat( aw)
:
 Sor eThroat(Pananakitngl
alamunan/masaki
tl
umunok) ✓
 BodyPai n( Pananaki
tngkatawan) ✓
 Headache(
Pananaki
tngul
o) ✓
 Fev
erLagnat
( ) ✓
 Cough(
Ubo) ✓
 ds(
Col Sipon) ✓
 Di
ff
icul
tyofbr
eat
hing(
Nahi
rapanghumi
nga) ✓
2.Haveyouwor kedtogetherorstayedinthesamecl oseenvi
ronmentwi t
haconf ir
medCOVI D ✓
-19caseorPUIundersel f-
quarantinei
ny ourhouseorinyournei ghbor
hood?
(Maynakasamakabaonakat rabahongtaonakumpi rmadongmayCOVI D-19/
mayi mpeksyonngcor onavi
rusoPUInakasamamonakaquar anti
nesabahayosa
kapit
bahay?)
3.Didyouhaveanycont actwithany onewit
hf ever
,cough,col
ds, andsor ethroati
nt hepast14 ✓
days?( Mayroonkabangnakasamanamayl agnat,ubo,siponosaki tngl alamunansa
nakali
pasnal abi
ng-apat(14)naar aw?
4.Haveyoutr
av ell
edout
sideofthePhil
ippinesinthel
ast14days?(
Ikawbaaynagbi
yahesa ✓
labasngPil
ipinassanakal
ipasnalabing-apat(
14)naaraw?)
5.Doyouhaveanyofthefol
l
owi
ngcondi
ti
ons:
Sakasal
( ukuyan,
ikawbaaymay
roonngmgasumusunodnakundi
syon)
 60y
ear
sol
dandabov
e(Mayedadna60t
aonggul
angopat
aas) ✓
 Ongoingpr egnancy(Pagbubunti
s) ✓
 Hypertensi
on( Mataasangpr esyonngdugo) ✓
 Heartdisease(Sakitsapuso) ✓
 Diabet
esmel li
tus(Di
abet es) ✓
 Recurr
entasthmaat t
acks( Mayhi
ka) ✓
 Chroni
clungdi sease-ongoingPTBt r
eatment(Saki
tsabaga-gi
nagamotsat
uber
cul
osi
s ✓
oTB)
 COPD( ChronicObst r
uctivePulmonary
Disease) ✓
 CancerKanser
( ) ✓
 Bl
ooddy scrasias(Sakitsadugo) ✓
 Chr
oni
cli
verandki
dneydi Saki
seases( tsaat
ayat
bat
o) ✓
 Cur rentl
yunder goingdi al
ysistr
eat ment(Kasalukuyangginagamotsapamamagi tan ✓
ngdialy
sis)
 I mmunocompr omisedst atus(Sobrangmahi naangr esi
stensya) ✓
 Aut oimmunedi sease( Autoimmunenasaki t) ✓
 Ot herIlnesses(
l ibangsakit)
Ifullyunder standt hatitist hepolicyoft heOurLadyofFat i
maUni ver
sit
yt hatnoemploy eeregardlessof
statusshal lbeal l
owedt oreportforwor koncampusi fanyoftheabovement i
onedcondit
ionsarepr esent.An
empl oyee may only report backtowor
kafterf
ollowingthe14-
day quarantineprotocolandsubmi t
amedi cal
clearance/
fitt
oworkcert
if
icat
efromthe School Phy sician bef ore
reporti
ngoncampus.
Ial
sof
ull
yunder
standt
hat
shouldIhav
eanyoft
hepr
evail
i
ngcondit
ionsst
atedini
tem5, Ishal
l
onlybeal
lowedtor
eport
backtoworkwhenmymedi calcondit
ionhasimprovedandwi t
hmedi calclearancefrom theSchoolPhysi
cian
andtheHRD.TheHRDwi l
lissueaRet ur
ntoWor kcert
if
icat
ionwhichwi llalway sbeinmypossessi onwhi l
e
oncampus.

Forseni
orci
ti
zens:
Ifull
yunderst
andt
hatImustfol
lowtheprev
ail
ingguideli
nespr
escri
bedbyt
heCOVI
D-19
I
nter
-AgencyTaskForcefort
heManagementofEmergi
ngInf
ect
iousDiseases(I
ATF).

I
attestt
hatall
theinfor
mationgi
venabov
earetr
ueandcorr
ectandt
hatI
maybehel
dli
ablef
oranymisi
nfor
mati
onstated
herei
n.Ial soaut hori
zeOurLadyofFat imaUni v
ersi
tytocoll
ectandprocessdataindicat
edherei
nfort he
purposeofef f
ectingthecontrolofCOVID-19infect
ionandthatmypersonalinf
ormationareprot
ectedby
RA.10173( DataPr iv
acyActof2012)andt hatIam requi
redbyRA.11469(Bayani
hantoHealasOneAct )to
provi
det r
uthfuli
nformati
on.
Si
gnat
ureOv
erPr
int
edName:

GABRI
ELVI
LLEGASG.
Dat
e Oct
ober16,
2021