Self Assessment

Self Assessment Form

Collins Aerospace cares about the safety of you and your fellow workers. We are following the development of COVID-19 very closely. In compliance with the Philippine DOLE requirement for self assessment and in the interest of ensuring a safe and healthy work environment, we ask that you accomplish this self-assessment daily and recommend that you take your temperature prior to coming to work and on arrival home.

Have you had close contact (< 2 meters (6 feet) for 15 consecutive minutes or more) with a person who has been diagnosed with or suspected of having COVID-19?

A. in the last 5 days for fully vaccinated;

B. in the last 14 days for partially or unvaccinated

Please select.

Yes

No

In the last 10 days, have you experienced any of the following symptoms associated with COVID-19?

A. Sudden loss of smell without congestion or a new loss of taste;

B. Fever greater than 37.5°C/99.5°F, chills, cough, shortness of breath, difficulty breathing;

C. Unexplained headache, tiredness, muscle pain, diarrhea, nasal congestion, runny nose or sore throat

Please select.

Yes

No

In the last 10 days, have you tested positive for COVID-19, with or without symptoms?

Please select.

Yes

No

Name

ID No.

By submitting this Collins Aerospace Online Self-Assessment Form, I voluntarily and freely authorize, and give my specific and informed consent to the collection, storage, processing, sharing and releasing of all my COVID-19 related personal information for the implementation and execution of the Program, and as may be needed or legally required for public health purposes, including completion of the required master-listing and reporting to applicable local and national vaccine registries, consistent with personal and health information storage protocols under the Data Privacy Act of 2012