BAGUIO CITY HEALTH DECLARATION FORM*1

1. NAME (PANGALAN) : _____________________________________________________________

2. NATIONALITY (KABANSANAN): _____________________________________________________
3. AGE (EDAD): ____ SEX (KASARIAN) : ____ OCCUPATION (TRABAHO) : ______________________
4. CONTACT NUMBER (MATATAWAGANG NUMERO):
LANDLINE:_______________ CELLPHONE: _____________________
5. HOME ADDRESS (ADDRESS NG TAHANAN) : ______________________________ ___________
OFFICE ADDRESS (ADDRESS NG OPISINA) :____________________________________________
EMAIL ADDRESS: ________________________________________________________________
6. DATE AND PURPOSE OF VISIT (PETSA AT LAYUNIN NG PAGBISITA):
_______________________________________________________________________
7. TYPE OF VEHICLE Private, Bus, Garage, UV Express, Car/Van Rental (URI NG SASAKYAN, Pribado, Bus, Garahe, UV
Express, Car/Van Rental) : ________________ IF Bus, Garage, UV Express, Car/Van Rental (Kung Bus,
Garage,UV Express, Rentadong Auto/Van) ISULAT ANG PANGALAN NG KOMPANYA)_______________________
8. PLATE NUMBER OF VEHICLE (PLAKA NG SASAKYAN) :__________ ________
9. SEAT NUMBER IF BY Bus, Garage, UV Express, Car/Van Rental (NUMERO NG UPUAN KUNG SUMAKAY SA Bus,
Garage,UV Express, Rentadong Auto/Van) ____________________
10. PLACE OF DESTINATION IN BAGUIO CITY (LUGAR NA PUPUNTAHAN/TUTULUYAN SA BAGUIO CITY):
_______________________________________________________ ___________
11. FOREIGN COUNTRIES OR OTHER REGIONS THAT YOU HAVE VISITED IN THE LAST 14 DAYS (MGA BANSANG
BANYAGA O REHIYON NA IYONG NAPUNTAHAN SA NAKARAANG 14 NA ARAW):
____________________________ ____________________________ ________
12. HAVE YOU BEEN SICK OF ANY OF THE FOLLOWING IN THE LAST 14 DAYS (NAGKASAKIT KA BA SA
MGASUMUSUNOD SA NAKARAANG 14 NA ARAW) :

SICKNESS (KARAMDAMAN) YES (OO) NO (HINDII)

FEVER (LAGNAT)
COUGH (UBO)
COLDS (SIPON)
SORE THROAT (PANANAKIT NG LALAMUNAN)
DIFFICULTY IN BREATHING (HIRAP SA PAGHINGA)
DIARRHEA (MADALA NA PAGDUMI)

DECLARATION: I hereby certify that the above information is true and complete. I understand that
my failure to answer, or any false or misleading information given by me may be used as a ground
for the filing of cases against me under Articles 171 and 172 of the Revised Penal Code of the
Philippines, or Republic Act No. 11332, otherwise known as the “Law on Reporting of
Communicable Disease”. (Ako ay nagpapatunay na ang mga impormasyon na aking binigay ay totoo
at kumpleto. Naiintindihan ko na ang kung anumang maling impormasyon ay maaring maging
dahilan para sa paghain ng kasong criminal laban sa akin sa ilalalim ng Article 171 at 172 ng Revised
Penal Code o sa ilalim ng Republic Act No. 11332).

____________________________________________ SIGNATURE OVER NAME (PANGALAN AT PIRMA

_______________________ DATE (PETSA)

*1 As a precautionary measure by the City of Baguio against the transmission of COVID-19, pursuant to Proclamation No. 922, dated 8 March
2020, and the Section 16 of the Local Government Code