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 (URI NG SASAKYAN):________________________________
8. PLATE NUMBER OF VEHICLE (PLAKA NG SASAKYAN):__________________
9. SEAT NUMBER IF BY BUS (NUMERO NG UPUAN KUNG SUMAKAY SA
BUS)_________________________
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 MGA SUMUSUNOD SA NAKARAANG 14 NA ARAW) :
YES (OO) NO (HINDI)
FEVER (LAGNAT)
COUGH (UBO)
COLDS (SIPON)
SORE THROAT
(PANANAKIT NG
LALAMUNAN)
DIFFICULTY IN
BREATHING (HIRAP SA
PAGHINGA)
DIARRHEA (MADALAS
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)

1As 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.