MSEUF STUDENT'S Personal Information
Student Number
Student Name
Sex
Age
Residence
Nature of Visit:
Destination
Co-morbidities: If Yes, check the box below and attach the Medical Certificate.

1. Are you experiencing for the past 5 days the following:(nakararanas ka ba ng:)

a. Sore throat (pananakit ng lalamuan / masakit lumunok)

 

b. Body pains (pananakit ng katawan)

 

c. Headache (pananakit ng ulo)

 

d. Fever for the past few days T – 37.5 (lagnat sa mga nakalipas na araw T – 37.5)

 

e. Cough (Ubo)

 

f. New onset or worsening shortness of breath nahihirapang huminga

 

g. Colds (Sipon)

 

h. Diarrhea (pagtatae)

2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?

(May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19 /may impeksyon ng coronavirus?)

    I hereby authorize MANUEL S. ENVERGA UNIVERSITY FOUNDATION, INC. to collect and process the 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, Data Privacy Act of 2012, and that I am required by RA 11496, Bayanihan to Heal as One Act, to provide truthful information.




Body Temperature :