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Department of Education: Health Declaration Form

This document is a health declaration form from Parara National High School that collects information from individuals such as name, nationality, contact details, recent travel history, health conditions, and contact with people from areas affected by disease. It asks if the individual has traveled to foreign countries, cities in the Philippines, been sick in the last 30 days, exhibited COVID-19 symptoms in the last 14 days, been in contact with farm/wild animals, or been in contact with people from Manila, Cebu or foreign countries in the last 14 days. It states that providing false information can have legal consequences.

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Vanessa Abaricio Tigres
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69 views2 pages

Department of Education: Health Declaration Form

This document is a health declaration form from Parara National High School that collects information from individuals such as name, nationality, contact details, recent travel history, health conditions, and contact with people from areas affected by disease. It asks if the individual has traveled to foreign countries, cities in the Philippines, been sick in the last 30 days, exhibited COVID-19 symptoms in the last 14 days, been in contact with farm/wild animals, or been in contact with people from Manila, Cebu or foreign countries in the last 14 days. It states that providing false information can have legal consequences.

Uploaded by

Vanessa Abaricio Tigres
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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Republic of the Philippines

Department of Education
REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF ILOILO
PARARA NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM

NAME: ________________________________________ ________________________________________ ________________________________


(LAST ) (FIRST) (MIDDLE)

NATIONALITY: ______________________________________ SEX: ___________________ AGE:


_______________________

E-MAIL ADDRESS: _________________________________________________ CONTACT NO.:


________________________________

ADDRESS: ____________________________________ ____________________________________ __________________________________


(BARANGAY) (MUNICIPALITY) (PROVINCE)

Kindly answer the following questions truthfully. Thank you.

 Foreign Countries you have worked, visited, transited or travelled to in the past 14 days
YES: _____ If YES, where (kindly write complete address of location)

NO: _____ _____________________________________________________________________________________

 Cities in the Philippines you have worked, visited, transited or travelled to in the past 14 days
YES: _____ If YES, where (kindly write complete address of location)

NO: _____ _____________________________________________________________________________________

 Have you been sick for the past 30 days:


YES: _____ If YES, where (kindly describe your condition)

NO: _____ _____________________________________________________________________________________

 Did you have any of the following in the last 14 days: FEVER, COLDS, COUGH, SORE THROAT, OR DIFFICULTY
OF BREATHING:
YES: _____ If YES, where (kindly specify)

NO: _____ _____________________________________________________________________________________

 Have you been close contact with farm animals exposed to wild animals in the past 14 days?
YES: _____ If YES, where (kindly describe circumstances)

NO: _____ _____________________________________________________________________________________

 Have you been close contact with persons who went home from MANILA, CEBU, and FOREIGN countries in the past 14
days?
YES: _____ If YES, where (kindly write exact address he/she came from)

NO: _____ _____________________________________________________________________________________

DECLARATION:
The information I have given herein is true, correct and complete. I understand that the failure to answer any or any falsified
response may have serious consequences. (Article171and 172 of the Revised Penal Code of the Philippines.
___________________________________________
____________
Signature over Printed Name

_____________________________________
_____

Address: Parara Sur, Tigbauan, Iloilo


Tel. No. (033) 511-7010
e-mail: [email protected]
Republic of the Philippines
Department of Education
REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF ILOILO
PARARA NATIONAL HIGH SCHOOL

Date

Address: Parara Sur, Tigbauan, Iloilo


Tel. No. (033) 511-7010
e-mail: [email protected]

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