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Internal Health Declaration Form
*
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Month
*
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January
February
March
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Day
*
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Name
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Eugene
Lito
Marla
William
Tonette
Jr
Jon
Dolly
Ida
Noli
Karen
Lulu
Cocoy
Reggie
Denah
Mark Anthony
Angelo
Edelyn
Jason
Duane
Macy
Robert
Richard
Edelyn
Sue
Jesan
Sherene
Sherryl
Mary Jane
Marvin
Office
*
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Quezon City
Culion
Coron
Zamboanga
Pagadian
Calapan
Bicol
Temperature
*
AM/PM
*
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AM
PM
Temperature
*
AM/PM
*
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AM
PM
Are you experiencing following symptoms?
*
None
Sore Throat
Body Pains
Headache
Fever
Cough
Diarrhea
Mode of transportation in going to the office?
*
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Public
Private
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