By signing this document, I hereby authorize the company 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). I know that I am required to provide truthful information as requested by RA 11469 (Bayanihan to Heal As One Act).

I certify that as of today, I am submitting this Health & Safety Check Declaration and Questionnaire voluntarily and with full knowledge and understanding of its safety purpose. It is also my genuine desire to preserve good health and well-being of everyone in my workplace and my home.

The Company had completely and repeatedly provided and advised me of all COVID-19 required safety and precautionary measures. For my part, I completely understand and I am fully aware of the risks and safeguards I need to undertake for my safety and those of my co-workers.

In rendering this disclosure, I hereby render the Company free and harmless from any claim of any nature whatsoever. I also declare that I have conducted myself in a safe and healthy manner inside the company as well as outside, recognizing that any afflication that I gather outside may harm my fellow workers in the office.