Stellar Cares For You Here in Stellar, your safety is paramount. Help us protect your health by filling out this form, in compliance with the Department of Health (DOH)’s contact tracing measures. Rest assured that all your data will be properly secured and protected. Temperature Fullname Mobile no. Address Age Gender Male Female Country of Residence Email (please enter a valid email address) 1. Are you experiencing or have you experienced any of the following symptoms in the last 14 days? SORE THROAT Yes No BODY PAINS Yes No HEADACHE: Yes No FEVER: Yes No COUGH: Yes No COLDS: Yes No LOSS OF SMELL AND/OR TASTE Yes No DIFFICULTY IN BREATHING Yes No 2. In the last 14 days, have you worked with or stayed in the same close environment with anyone suspected of or confirmed with COVID-19? Yes No 3. In the last 14 days, have you had close contact with anyone experiencing any COVID-19-related symptoms (e.g. fever, cough, colds, etc.)? Yes No 4. In the last 14 days, have you travelled outside of the Philippines? Yes No Acceptance By checking this, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any of the questions or giving false answers can be penalized in accordance with the law. I also hereby authorize Stellar Potter's Ridge to collect my data indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by RA 10173, under the Data Privacy Act of 2012, and that I am required by RA 11469 or Bayanihan Heal As One Act to provide truthful information. Moreover, I understand that this Health Declaration Form is being made pursuant to DTI and DOLE Guidelines on Workplace Prevention and Control of COVID-19. Send
