“NGCP BRIDGING OWERA PROGRESS NGCP HEALTH AND TRAVEL DECLARATION FORM armex Acrev? GUEST = rounanr€elelandrn Kerth flan: Mace: 25 navionauines (LastName Prst Name Mile (CURRENT ADDRESS IN THE PHILIPPINES: Serfap_ Arai Neg. Upp Rees (Huse nanber hes Boangayond mena) eat anpness: Seletemdenghec(@zpoail. Com ‘VENUE: ‘CONTACT NO. IN THE PHILIPPINES: ‘CONTACT PERSON IN NGCP: PURPOSE OF VISIT IN NGCP: DATES OF VISIT IN NGCP: 1. Deyou have fever that caual to orhicher than 37°C Tn the past 10 dave? have you taken ante-fever medication the past 10 days? Z—Hlave you had eough and/or dificult of breathing in the past 10 da ‘Have you had any close contact with a SUSPECTED COVID-19 patient (patient with ever, ‘cough, and/or difficulty of breathing) in the past 14 days? | 7. Have sou had any close contact with a PROBABLE COVID-I9 patient (auspected patent tested for COVID-19 but with negative/Inconclusive/pending resul) in the past 4 days? "Have you Rad any close contact with a CONFIRMED COVID-19 patient inthe past 14] days i SCREENING QUESTIONS Ts tf I REMINDERS: ‘+ Your addresses and contact information are vital in the conduct of CONTACT TRACING for containment of the occurrence of COVID-19 in casea positive casei found. ‘+ Foryour addresses: Your complete address will include house nSoumber, street, barangay, and municipality. For ranslent visitor, can be the name of hotel where you are staying in the Philippines + For your contact number: Your contact number must be the local mobile number, landline, oF mobile numberof fiend/relative where you ae staying in the Philippines. DATA PRIVACY Inti with the Dota Privacy Ac of 2012 (DPA), please be informed that NCP will be handling our personal and heath Information in reoton tothe COVID-19 Assesment Al personal dara acquired by NGCP fram this assessment shall only be used for COVID-19 sreening purposes by authorized NGCP representatives and shall not be further processed or disclosed without the consent of the signatory unless required by government instrumentals for purposes of contact tracing. Retention of your personal formation shal be Jor a period of one (1) year from the date ofsubmision. Beyond {his drs sin documant a any ther rend af yt porenal Information frm thie ranenton coll he Aged oF According to che Company’ procedures. The above information provided in this Health and Travel Declaration Form are true, complete and correct. { understand that I may be held lawfully liable for any omission, false information or Imizintcrpretation made herein, especially If such action resulted to under exposure of workers and ‘the general public to the risks of COVID-19. Further, I allow NGCP to process my personal information stated herein accordance with the company’s Data Privacy regulations. Signature of Guest overperthted Name, Date