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COVIDDECLARATIONFORM1

1. It asks individuals to report if they have experienced any COVID-19 symptoms in the last 14 days or had contact with confirmed COVID-19 cases. 2. It collects personal information like name, address, and phone number. 3. The individual certifies the information is true and understands failure to disclose or providing false information could have serious consequences.

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Jenny Jean Auro
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36 views1 page

COVIDDECLARATIONFORM1

1. It asks individuals to report if they have experienced any COVID-19 symptoms in the last 14 days or had contact with confirmed COVID-19 cases. 2. It collects personal information like name, address, and phone number. 3. The individual certifies the information is true and understands failure to disclose or providing false information could have serious consequences.

Uploaded by

Jenny Jean Auro
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 IV- A CALABARZON
SCHOOLS DIVISION OF BATANGAS
LIAN DISTRICT
LUYAHAN ELEMENTARY SCHOL

HEALTH
DECLARATION
Time
{Oras)
FORM

Full Name (Buong Date {Petsa)


Pangalan) a. Fever (MM/DD/VY):
Complete Current Address (Lagnat)
(Kasalukuyang
tirahan):
Mobile/Phone Number {Numero ng
telepono)
EmailPutAddress:
a check mark on the appropriate column of your response. (Lagyan ng tsek
sa angkop na sagot.)
Yes (Oo No
1. Are you experiencing b. Cough and/or Colds (Ubo at/o Sipon) (Hindi)
or c. Body pains (Pananakit ng katawan)
did you have any of the d. Sore Throat (Pananakit o pamamaga ng
following in the last 14 lalamunan)
days? Ikaw ba ay may
nararanasan o e. Fatigue/Tiredness (Pagkapagod)
nakaranas ng mga f. Headache (Pananakit ng ulo)
sumusunod na
3. Have you provided direct care for a(Pagtatae)
g. Diarrhea patient with probable or
sintomas sa
confirmed COVID-19 case h Loss of taste orproper
without using "Personal ng
smell(Nawalan Protective
panlasa
nakaraang(PPE)"
Equipment 14 na for the past 14 days?
o pang-amoy) (Nag- alaga ka ba ng
2. Have you
maaring had face-to-face
o kumpirmadong contact with
pasyente a probable
na may or confirmed
COV/D-19 ng hindi
COVID-19ngcase
nakasuot tamang 1i.meter
withinPPE Difficulty
and for
(Personal of breathing
more (Pagkahapo
thanEquipment)
Protective 15 sao the
minutes for
past 14 days?
nakalipas na 14(May hirap sa pagkahinga)
nakasalamuha
araw?) ba na aaaring o
kumpirmadong pasyente na may COV/D-19 mula sa isang
metrong distansya or mas malapit pa at tumagal ng mahigit 15
minuto sa nakalipas na 14 araw?)

4. Have you traveled outside the Philippines in the last 14 days? Ikaw
ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
5. Have you traveled outside the current city/municipality where you
reside? Ikaw ba ay nagbiyahe sa labas ng iyong
lungsod/munisipyo?) If yes, specify which city/municipality you
went to (Sabihin kung saan)
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any question
or any falsified response may have serious consequences. 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 20 days from the date of
accomplishment, following the National Archives of the Philippines protocol.

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