Cordillera Career Development College Yes: ___ No: x

Buyagan, Poblacion, La Trinidad, Benguet If yes, where? _____________________________________

Date of arrival: _________________Date of departure: ________________
Health Declaration Form 6. Please list the places outside home that you had been to for the past 5 days
(Please include grocery stores, banks, market ,other public areas):
Instruction: This form is good for one week only. Please accomplish the following and send
Specific Place/s Date & Time Specific Address
to the HRD Office at hrd@ccdc.edu.ph, at least two working days before the scheduled
SM July 19, 2020/ 3:00 Pm Upper Session Road
work days. You will be notified as soon as possible by the HRD officer after assessment by
______ ________________ ____________ _ _______ ________________
our Medical Staff. Please wait for your work permit to be issued before going to school.
_______ ________________ _____________ ________ _______________
Only those with work permits shall be allowed entry by the school guards. Also, kindly
_______ _____________ ________________ _______ ________________
submit the hardcopy of your accomplished form to the clinic upon entry in school.
____________________ ____ __________________ ________________________
________________________ ________________ ________________________
Name: Ricel jeremiah D. Surla Sex: F Age: 23
________________________ ________________ ________________________
Complete Address: 88k- Sixto gearlan St. brower Rd, Brgy. Campo Filipino, Baguio City
Department: College of Teacher education
7. Requested dates, time to be in school: July 22, 2020/ 1:00 Pm
Purpose: Library work, finishing course guideline
Please answer the following truthfully.
______________________________________________________________
1. Are you experiencing:
a. Sore throat? Yes: ___ No: x
b. Body pains? Yes: ___ No: x
c. Headache? Yes: ___ No: x Declaration
d. Difficulty of I hereby authorize the Cordillera Career Development College, to collect and process the data
indicated herein for the purpose of effecting control of the COVID -19 infection. I understand that
Breathing? Yes ___ No: x
my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required
e. Fever for the by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.
Past few days? Yes: ___ No: x
2. Have you stayed in the same close environment of a confirmed COVID- 19 I certify that the above information is true and complete. I understand that failure to answer, or any
case? Yes: ___ No: x false or misleading information given by me may be used as a ground for the filing of cases against
3. Have you had any contact with anyone with fever, cough, and sore throat in me under Articles 171 and 172 of the Revised Penal Code or of Republic Act No. 11332, otherwise
the past 2 weeks? Yes: ___ No: x known as the law on Reporting of Communicable Disease.
4. Have you travelled outside the Philippines in the last 14 days?
Yes: ___ No: x Signature over Printed Name:RICEL JEREMIAH D. SURLA
Date: JULY 22, 2020
If yes, where? ___________________________________
Date of Arrival: _________________Date of departure: _________________
Thank you. Your honesty can save lives!
5. Have you travelled outside Benguet in the past 14 days?