QCU DAILY HEALTH ASSESSMENT

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Email *

DATE *

YYYY

FULL NAME (LAST NAME, FIRST NAME MIDDLE INITIAL) *

CONTACT NUMBER: *

Office/ Department/ Division *

OFFICE OF THE PRESIDENT

OVPAF

OVPAA

FINANCIAL MANAGEMENT DIVISION

ACCOUNTING DIVISION

HRD

PHYSICAL FACILITIES

REGISTRAR / ADMISSION

ICT / MIS

SASD

MEDICAL AND DENTAL SERVICES

LIBRARY

SCHOLARSHIP

GUIDANCE

REPL

INFORMATION TECHNOLOGY

ENTREPRENEURSHIP

ENGINEERING

ACCOUNTANCY

GENERAL EDUCATION

NSTP

PHYSICAL EDUCATION

QACIMD

PSPMD

BODY TEMPERATURE *

ARE YOU VACCINATED? *

BOOSTER

FIRST DOSE

SECOND DOSE

Have you had experience the following symptoms TODAY? *

Fever

Cough/ Colds

Sore throat

Diarrhea

Headache

Body pain

Loss of taste and smell

None of the above

Other:

Required

HAVE YOU BEEN IN CLOSE CONTACT TO SUSPECTED OR CONFIRMED COVID CASE FOR THE PAST 14 DAYS? *

Yes

HAVE YOU BEEN TESTED FOR COVID IN THE PAST 10 DAYS/ *

ANTIGEN TEST

RAPID TEST

RT PCR

ARE YOU CURRENTLY AWAITING RESULTS? *

Yes

I hereby authorized QCU to collect and process the data indicated herein for the purpose of affecting control of COVID- 19 infection. I understand that my personal information is protected by DATA PRIVACY ACT of 2012 (RA10173) and that I am required under the BAYANIHAN TO HEAL AS ONE ACT (RA11469), to provide truthful information. *

Yes

A copy of your responses will be emailed to the address you provided.

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