Name *

First Name

Last Name

Are you currently experiencing any type of the following symptoms: Sore throat, Body Pains, Headache and Fever? *

Yes

No

Declaration and Data Privacy Consent *

The information I have given is true, correct, and complete. I understand that failure to answer any question or giving false answer can be penalized in accordance with law. I voluntarily and freely consent to the collection and sharing of the above personal information in relation to RCOC COVID-19 internal protocols and for the purpose of affecting control of the COVID-19 infection as required by R.A. 11469, Bayanihan to Heal as One Act.

Agree