Word For
Word For
Word For
I hereby authorize Polytechnic University of the Philippines to collect and process the data indicated herein for the
purpose of mitigating COVID-19 (Corona Virus 2019). I understand that my personal information is protected by RA
10173, Data Privacy Act of 2012, and that I am required by RA 11469 , Bayanihan to Heal as One Act, to provide
truthful information.
SIGNATURE
Visual Triage Checklist for COVID-19
NAME:
PangalanLast NameGiven NameMiddle Name
CONTACT DETAILS:
TeleponoHome Telephone Number Mobile No.
ASSESSED BY:
Nurse Doctor