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Contact Tracing Form

This document is a contact tracing form used by Barangay Pilitan, Tumauini, Isabela to collect personal information from clients and visitors such as name, address, contact number, temperature, and signature. The information is collected for contact tracing to control the spread of COVID-19. Users authorize the barangay to collect and process their data according to the Data Privacy Act of 2012. The forms will be destroyed after 30 days following archival protocols.

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Virgo Cayaba
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© © All Rights Reserved
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96 views1 page

Contact Tracing Form

This document is a contact tracing form used by Barangay Pilitan, Tumauini, Isabela to collect personal information from clients and visitors such as name, address, contact number, temperature, and signature. The information is collected for contact tracing to control the spread of COVID-19. Users authorize the barangay to collect and process their data according to the Data Privacy Act of 2012. The forms will be destroyed after 30 days following archival protocols.

Uploaded by

Virgo Cayaba
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CLIENT/VISITOR CONTACT TRACING FORM CLIENT/VISITOR CONTACT TRACING FORM

Name : ________________________________________________ Date of visit: _______________________ Name : ________________________________________________ Date of visit: _______________________
Address : ______________________________________________ Time of visit: _______________________ Address : ______________________________________________ Time of visit: _______________________
Contact Number : _________________________________________ Contact Number : _________________________________________
Temp. ________________
Temp. ________________
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
indicated herein for the purpose of contact tracing effecting control of the COVID-19
indicated herein for the purpose of contact tracing effecting control of the COVID-19
transmission. I understand that my personal information is protected by RA 10173 or the
transmission. I understand that my personal information is protected by RA 10173 or the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
date of accomplishment, following the National Archives of the Philippines protocol.
date of accomplishment, following the National Archives of the Philippines protocol.
____________________________________ ____________________________________

Signature over printed name Signature over printed name

CLIENT/VISITOR CONTACT TRACING FORM CLIENT/VISITOR CONTACT TRACING FORM

Name : ________________________________________________ Date of visit: _______________________ Name : ________________________________________________ Date of visit: _______________________
Address : ______________________________________________ Time of visit: _______________________ Address : ______________________________________________ Time of visit: _______________________
Contact Number : _________________________________________ Contact Number : _________________________________________
Temp. ________________
Temp. ________________
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
indicated herein for the purpose of contact tracing effecting control of the COVID-19
indicated herein for the purpose of contact tracing effecting control of the COVID-19
transmission. I understand that my personal information is protected by RA 10173 or the
transmission. I understand that my personal information is protected by RA 10173 or the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
date of accomplishment, following the National Archives of the Philippines protocol.
date of accomplishment, following the National Archives of the Philippines protocol.
____________________________________ ____________________________________

Signature over printed name Signature over printed name

CLIENT/VISITOR CONTACT TRACING FORM CLIENT/VISITOR CONTACT TRACING FORM

Name : ________________________________________________ Date of visit: _______________________ Name : ________________________________________________ Date of visit: _______________________
Address : ______________________________________________ Time of visit: _______________________ Address : ______________________________________________ Time of visit: _______________________
Contact Number : _________________________________________ Contact Number : _________________________________________
Temp. ________________
Temp. ________________
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
indicated herein for the purpose of contact tracing effecting control of the COVID-19
indicated herein for the purpose of contact tracing effecting control of the COVID-19
transmission. I understand that my personal information is protected by RA 10173 or the
transmission. I understand that my personal information is protected by RA 10173 or the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
date of accomplishment, following the National Archives of the Philippines protocol.
date of accomplishment, following the National Archives of the Philippines protocol.
____________________________________ ____________________________________

Signature over printed name Signature over printed name

CLIENT/VISITOR CONTACT TRACING FORM CLIENT/VISITOR CONTACT TRACING FORM

Name : ________________________________________________ Date of visit: _______________________ Name : ________________________________________________ Date of visit: _______________________
Address : ______________________________________________ Time of visit: _______________________ Address : ______________________________________________ Time of visit: _______________________
Contact Number : _________________________________________ Contact Number : _________________________________________
Temp. ________________
Temp. ________________
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
I hereby authorize Barangay Pilitan, Tumauini, Isabela to collect and process the data
indicated herein for the purpose of contact tracing effecting control of the COVID-19
indicated herein for the purpose of contact tracing effecting control of the COVID-19
transmission. I understand that my personal information is protected by RA 10173 or the
transmission. I understand that my personal information is protected by RA 10173 or the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
Data Privacy Act of 2012 and that this form will be destroyed after thirty (30) days from the
date of accomplishment, following the National Archives of the Philippines protocol.
date of accomplishment, following the National Archives of the Philippines protocol.
____________________________________ ____________________________________

Signature over printed name Signature over printed name

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