CESU

COVID-19 Self-Reporting System

1. Patient Information

Pakibasang maigi:

Lahat ng detalye na may markang asterisk (*) ay kailangang sagutan. Kung hindi kailangang sagutan ang walang asterisk, maaaring iwanan lang na blanko kung N/A. Ibigay lamang ang totoo at tamang impormasyon upang maiwasan ang mga parusang ayon sa batas.

Personal Information

*Apelyido

*First Name (and Suffix)

Middle Name (Leave blank if N/A)

*Birthdate

*Gender

*Are you Pregnant?

*Last Menstrual Period (LMP)

*Civil Status

*Nationality

*Mobile Number (Format: 09*********) Note: Please type your CORRECT and ACTIVE Mobile Number as we will use this to contact you.

Philhealth Number (Leave blank if N/A) (12 Numbers, No Dashes)

Telephone Number (& Area Code) (Leave blank if N/A)

Email Address (Leave blank if N/A)

Note: Special Characters such as ! @ # _ $ , . ( ) etc. are not allowed to input in the adress bar.

*Province

*City or Municipality

*Barangay

*House No./Lot/Building

*Street/Purok/Sitio/Subdivision Kung N/A, lagyan ng pinakamalapit na establisyemento kung saan ka nakatira (e.g Near Brgy. Hall, Near Alfamart, Near Tulay, Near Ilog, etc.)

Occupation Details

*Kasalukuyan ka bang may trabaho?

Notice: starting October 06, 2021. Name of Company/Workplace and Complete Company/Workplace Address are now required fields to be filled up. This is to comply with the requirements of the Molecular Laboratory.

*Trabaho

*Saan nagt-trabaho

*Uri ng Trabaho

*Tukuyin

*Works in a closed setting?

*Workplace Province

*Workplace City

*Workplace Barangay

*Workplace Lot/Building

*Workplace Street/Avenue

Workplace Phone/Mobile No. (Optional)

Workplace Email (Optional)

Special Population

*Health Care Worker

*Name of Health Facility

*Location

*Returning Overseas Filipino

*Country of Origin

*Passport No.

*OFW?

*Foreign National Traveler

*Country of Origin

*Passport No.

*Locally Stranded Individual/APOR/Traveler

*Province of Origin

*City of Origin

*Type

*Lives in Closed Settings

*Specify Institution Type (e.g. prisons, residential facilities, retirement communities, care homes, camps etc.)

*Name of Institution

2. Case Investigation Details

*Type of Client

Personal Message to CESU Staff/Encoders (Optional)

Consultation Information

*Have previous COVID-19 related consultation?

*Name of facility where first consult was done

*Date of First Consult

3. COVID-19 Vaccination Information

*Ikaw ba ay bakunado na kontra COVID-19? / Are you currently vaccinated againts COVID-19?

*Ilang Dose na ang nakumpleto? / How many Dose have you completed?

*Name of Vaccine Vaccine Name not Included in the List? You may contact CESU Staff.

*1.) First (1st) Dose - Date of Vaccination

Vaccination Center/Facility (Optional)

Region of Health Facility (Optional)

*Adverse Event/s

*2.) Second (2nd) Dose - Date of Vaccination

Vaccination Center/Facility (Optional)

Region of Health Facility (Optional)

*Adverse Event/s

*Booster Vaccine Name Vaccine Name not Included in the List? You may contact CESU Staff.

*Booster Date Vaccinated

*Booster Adverse Event/s

Booster Vaccination Center/Facility (Optional)

Booster Region of Health Facility (Optional)

*Have 2nd Booster Vaccine?

*2ND Booster Vaccine Name Vaccine Name not Included in the List? You may contact CESU Staff.

*2ND Booster Date Vaccinated

*2ND Booster Adverse Event/s

2ND Booster Vaccination Center/Facility (Optional)

2ND Booster Region of Health Facility (Optional)

4. Clinical Information

*Kasalukuyan ka bang nakakaranas ng senyales o sintomas ng COVID-19? / Are you currently experiencing any COVID-19 signs or symptoms?

5. Laboratory Information

*Have you ever tested positive using RT-PCR before?

*Number of previous RT-PCR swabs done

*Date of Specimen Collection

Laboratory

*Date Collected

*Date released

*Laboratory

*Type of test

*Specify Reason

*Antigen Kit

*Upload Positive Result Document/Form Accepted file formats: JPG, JPEG, PNG, PDF. Max file size: 5MB

6. Chest X-ray Details

*Was diagnosed to have Severe Acute Respiratory Illness?

*Kailan natapos / Date done

*Uri ng Chest X-Ray / Chest X-Ray Type

*Resulta / Results

*Tukuyin / Specify findings

Data Privacy Statement of General Trias

Sa pamamagitan ng pagpili ng "Sumasang-ayon ako" at pag-click sa pindutang "Isumite" sa ibaba, kinikilala ko at napatunayan na maingat kong binasa at naintindihan ang Mga Tuntunin at Kundisyon ng Patakaran sa Data Privacy/Polisiya ng Pamahalaan ng Lungsod ng General Trias. Sa pamamagitan ng pagbibigay ng personal na impormasyon sa Pamahalaang Lungsod ng General Trias, kinukumpirma ko na ang data ay totoo at tama. Naiintindihan ko na ang Pamahalaang Lungsod ng General Trias ay may karapatang baguhin ang anumang desisyon na ginawa batay sa impormasyong ibinigay ko kung ang impormasyon ay mapatunayan na hindi totoo o hindi tama. Sumasang-ayon din ako na ang anumang isyu na maaaring lumabas na may kaugnayan sa pagproseso ng aking personal na impormasyon ay maaayos sa Pamahalaang Panlungsod ng General Trias bago gamitin ang naaangkop na arbitrasyon o paglilitis sa korte sa loob ng hurisdiksyon ng Pilipinas. Sa wakas, nagbibigay ako ng aking kusang-loob na pahintulot at permiso sa Pamahalaang Lungsod ng General Trias at ang mga kinatawan na pinahintulutan na ligal na maproseso ang aking data / impormasyon.

Sumasang-ayon ako / I Agree

Note: If errors/issues has been found or if site not working properly, please contact CESU Staff Immediately.