Student – Coronavirus (COVID-19)

COVID-19
Screening Tool

This tool was developed to assess BukSU personnel’s current health condition in this time of COVID-19 pandemic.

Let’s all look out for each other by knowing our status, trying not to infect others and keeping everyone safe.

After accomplishing the tool, the system will automatically generate a QR Code, sent to your email, which you shall present to the guard on duty for inspection.

COVID-19 Screening Tool

You will answer few questions about symptoms, travel(s), and contact(s) you have had with others.
Rest assured that the data gathered in this screening tool will be treated with utmost confidentiality.
Any information obtained from this tool shall not be used as diagnosis and/or treatment of any medical condition.

Personal Information

First Name *

Last Name *

Middle Name *

Sex *

Male Female

Age *

Email Address *

Phone Number *

Location during the ECQ/ GCQ (Province) *

Work Related Information

ID Number *

student type *

College

High School

Elementary

Place of Campus *

Main Campus

Satellite Campus

Health Related Information

Please check if you have or had experienced any of the following for the past 2 weeks *

Fever (Temperature of 37.8°C and ABOVE)

Cough AND/OR Colds

Shortness of Breath

Sore Throat

Diarrhea (Loose Bowel Movement)

None of the Above

Underlying conditions that you have in any of the following *

Diabetes Mellitus Type I or II

Cardiovascular Disease (Heart Condition)

Chronic Kidney Disease

Chronic Liver Disease

Cancer

Bronchial Disease (Lung Condition, Asthma/COPD)

Other Conditions

None of the Above

Have you lived or recently travelled to countries/areas that has reported LOCAL TRANSMISSION or POSITIVE CASES of COVID-19? *

Yes No

Have you been exposed to persons with history of travel to countries/areas that has reported LOCAL TRANSMISSION or POSITIVE CASES of COVID-19? *

Yes No

Municipality / Town / City *

I hereby certify that the information that I have given above are true, accurate and complete. I understand that failure to answer any of the questions honestly to the best of my ability or wilfully falsifying a response constitutes a violation of the law under RA 11332.

BukSU COVID-19 Secretariat

taskforcecovid-2019@buksu.edu.ph

BukSU COVID-Hotline

09564074455