COVID-19 HEALTH DECLARATION FORM

In compliance with the National IATF, Department of Tourism, and City Government guidelines in preventing and controlling
the spread of Covid-19, all guests are required to fill out this form completely. All information provided shall be subject to
verification and validation in compliance with relevant laws. Rest assured that your information will be treated with
confidentiality.

Name:______________________________________________________________ Age:____________ Sex: _________ Nationality:_______________________

Email Address: _________________________________________________________________ Contact Number: ____________________________________
Complete Address: ______________________________________________________________________________________________________________________
Complete Address Abroad (If living overseas): ______________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
Government ID presented (including ID number): ___________________________________________________________________________________

QUESTIONNAIRE (Please check):

YES NO

1. Have you travelled to or came from a municipality/city with confirmed COVID-

19 cases in the last 14 days?

2. Have you had recent contact with a person with a confirmed or suspected case
of COVID-19?
3. Do you have symptoms such as FEVER greater than 37.5 degrees Celsius and flu-
like symptoms such as COUGH, DIFFICULTY OF BREATHING, or SHORTNESS
OF BREATH?

Guest's COVID-19 Status (For Accommodation Establishment Personnel):

_______ Probable COVID-19: Please check if the guest answered YES to ANY of the 3 questions above. Refer to the City Health
Office’s City Epidemiology and Surveillance Unit immediately.

_______ Negative COVID-19: Please check if the guest answered NO to ALL of the 3 questions above.

TRAVEL DETAILS:

⮚ Date of arrival in BICOL: ________________________________________

⮚ Date of arrival in NAGA (leave blank if the same as above):__________________________________________
⮚ Mode of transportation to BICOL (please include flight no./trip code if applicable): ___________________________________
⮚ Mode of transportation to NAGA (please include flight no./trip code if applicable): ___________________________________
⮚ Most recent place of origin: _____________________________________________

SIGNS AND SYMPTOMS (If applicable): _____________________________________________________________________________________________

DATE OF ONSET OF SIGNS AND SYMPTOMS (If applicable): _______________________________

I hereby certify that the information I have provided are Verified by:
true and correct:

________________________________________________________ ________________________________________________________
Signature over Printed Name of Guest Signature over Name and Designation

Note: The management shall submit this form to the Arts, Culture and Tourism Office (ACTO) every Friday for record and contact tracing
purposes. Failure to do so shall constitute a violation of applicable laws and policies.