HEALTH SERVICES OFFICE

HEALTH CHECKLIST/DECLARATION FORM

NAME: ________________________________________________________________ AGE: ______ TEMP: __________________
ADDRESS: ______________________________________________________________________________________ CONTACT #: _________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS TRUTHFULLY. TICK YES/NO

1. Have you traveled recently for the past 14 days outside Cagayan Valley?
2. Did you have any travel history to any CoViD-19 infected area?
3. Do you have a direct contact or is taking care of a CoViD positive patient?
4. Do you have cough, colds, diarrhea, sore throat or a temperature of 37.8 C or above?
5. Have you been sick from cough, colds, diarrhea, fever and sore throat for the past 14 days?

DECALARATION: I hereby certify that the above information is true and complete. Any false declaration may hold me
criminally liable for violation of RA 11332 otherwise known as the “Law on Reporting of Communicable Diseases”.
_________________________________________________________________________ _______________________________
Signature over Printed Name Date and Time

HEALTH SERVICES OFFICE

HEALTH CHECKLIST/DECLARATION FORM
NAME: ________________________________________________________________ AGE: ______ TEMP: __________________
ADDRESS: ______________________________________________________________________________________ CONTACT #: __________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS TRUTHFULLY. TICK YES/NO

1. Have you traveled recently for the past 14 days outside Cagayan Valley?
2. Did you have any travel history to any CoViD-19 infected area?
3. Do you have a direct contact or is taking care of a CoViD positive patient?
4. Do you have cough, colds, diarrhea, sore throat or a temperature of 37.8 C or above?
5. Have you been sick from cough, colds, diarrhea, fever and sore throat for the past 14 days?

DECALARATION: I hereby certify that the above information is true and complete. Any false declaration may hold me
criminally liable for violation of RA 11332 otherwise known as the “Law on Reporting of Communicable Diseases”.
_________________________________________________________________________ _______________________________
Signature over Printed Name Date and Time