Have you or any immediate family members been to any of the following affected country/countries in the last 14 days? ( China, Iran, South Korea, USA, Singapore and Italy)
Have you or any immediate family members come into close contact with confirmed case of COVID-19 Virus in the last 14 days?
Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness and difficulty breathing)?
I hereby voluntarily give my consent in providing my personal data or information for the purpose(s) described in this document. I also understand that my consent does not prevent the existence of other criteria for lawful processing of personal data and does not waive any of my rights under RA 10173 – Data Privacy Act of 2012 and other applicable laws.