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Self-Declaration Checklist Form

This document is a self-declaration checklist from AEI Enterprise, Inc. located in Lapu-Lapu City, Philippines. The checklist collects personal information such as name, nationality, gender, birthdate, address, and contact details. It asks questions about provinces visited in the last 14 days, current COVID-19 symptoms, and contact with infected individuals. The declaration states that all information provided is true and can be used in a court of law. A note at the bottom advises employees and visitors exhibiting symptoms or exposure to self-quarantine and not enter the company premises.

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Ritchelle Quijote Delgado
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52 views1 page

Self-Declaration Checklist Form

This document is a self-declaration checklist from AEI Enterprise, Inc. located in Lapu-Lapu City, Philippines. The checklist collects personal information such as name, nationality, gender, birthdate, address, and contact details. It asks questions about provinces visited in the last 14 days, current COVID-19 symptoms, and contact with infected individuals. The declaration states that all information provided is true and can be used in a court of law. A note at the bottom advises employees and visitors exhibiting symptoms or exposure to self-quarantine and not enter the company premises.

Uploaded by

Ritchelle Quijote Delgado
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

AEI ENTERPRISE, INC.

3rd flr. SFB1 PEZA MACTAN Lapu-Lapu City

Self - Declaration Checklist

Family Name : ___________________________________________________________


First Name : ___________________________________________________________
Middle Name: ___________________________________________________________
Nationality : ___________________________________________________________
Gender : ___________ Male __________ Female
Birthday : ______________ (Day-Month-Year) ______ Age
Present Address : _______________________________________________________
Mobile Number : _______________________________________________________

PART A
a. Details of the province/cities/town visited in the last 14 days? ____________________
_______________________________________________________________________

b. Are you suffering from any of the following symptoms?


Fever Yes No
Cough Yes No
Respiratory Distress Yes No
High Blood Temperature Yes No
Sneezing Yes No
Shortness of Breath Yes No
Sore Throat Yes No
Others _________________________________________

c. Have you been with a person/s under monitoring or under investigation or positive of
COVID - 19? __________ No ; ____________Yes

DECLARATION:

The information I have given above is true, correct and complete. That I am also aware that any false
information given by me will be used against me in the court of law.

_____________________________
Signature over Printed Name / Date

Note: Employees/visitors who developed flu-like symptoms, with travel history or exposure to Covid-19 positive persons are advised to go
on self –quarantine and are not allowed to enter inside the company premises.

Tel # (032) 340-2943 / 340-2945 / 340-0710 ✦Fax # (032) 340-2944 ✦ Email :  aeienterprise@[Link]

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