Enclosure No. 2 to Division Memorandum No. ___, s.

2020
Enclosure No. 2 to Division Memorandum No. ___, s. 2020
HEALTH DECLARATION FORM HEALTH DECLARATION FORM
Date of Visit: __________ Time: _____________ Date of Visit: _________________ Time:
Temperature: _________ Contact #:
_______________________ RESPONDENT INFORMATION
Last Name:
RESPONDENT INFORMATION
First Name:
Last Name:
Middle
First Name: Name:
Middle Sex: Male
Name: Nationality:
Age: Female
Sex: Male Nationality:
Age: Female School/District:
______________________________________
School/District:
______________________________________ Address: Barangay:
Address: Barangay: _____________________________ City/Municipality:
_____________________________ City/Municipality: _____________________________
_____________________________ Province: __________________ Region:
Province: __________________ Region: _________
Purpose of Visit:
_________
Purpose of Visit: 1. In the past 14 days, which of the following symptom(s) have you
1. In the past 14 days, which of the following symptom(s) have you experienced. Please check () the relevant box(es).
experienced. Please check () the relevant box(es). Fever
Fever Sore throat
Sore throat Diarrhea
Diarrhea Body aches
Body aches Headache
Headache Dry Cough
Dry Cough Tiredness
Tiredness Shortness of breath
Shortness of breath Runny Nose
Runny Nose Others
Others NONE OF THE ABOVE
NONE OF THE ABOVE 2. Have you been in contact with a confirmed COVID-19 patient in
2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?
the past 14 days?
Yes No
Yes No
3. Have you been identified to high risk areas of COVID-19 in the 3. Have you been identified to high risk areas of COVID-19 in the
past 14 days? past 14 days?

Yes No Yes No
If yes, please indicate the area(s): If yes, please indicate the area(s):
Declaration and Data Privacy Consent Form: Declaration and Data Privacy Consent Form:
The information I have given is true, correct and complete. I understand that The information I have given is true, correct and complete. I understand that
failure to answer any question or giving false answer can be penalized in failure to answer any question or giving false answer can be penalized in
accordance with law. accordance with law.
I voluntarily and freely consent to the collection and sharing of the above I voluntarily and freely consent to the collection and sharing of the above
personal information only in relation to the DepEd Dipolog Ciy, Zambaoanga personal information only in relation to the DepEd Dipolog Ciy, Zambaoanga
del Norte COVID-19 internal protocols. del Norte COVID-19 internal protocols.

__________________________ _____________ __________________________ _____________

Signature Date Signature Date

Please be advised that the above information shall only be used in relation to Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act. DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.
N-avigating "Be and Do Much N-avigating "Be and Do Much
Capitol Drive, O-pportunities to Capitol Drive,
Better Each Day
O-pportunities to
Estaka, Dipolog
Better Each Day ____________
R-eengineer for
Estaka, Dipolog
with a
R-eengineer for with a
T-ransformation &
City, 7100
Sense of Urgency" Temperature: _________
T-ransformation & Contact
City, 7100 #:
Sense of Urgency"
Tel No.: Tel No.:
E-mpowerment _________________
E-mpowerment
(065) 212- (065) 212-
5843 5843
e-mail e-mail
address: address:
zn.division zn.division
@deped.gov. @deped.gov.
ph ph
 N-avigating
O-pportunities to Capitol Drive, Estaka, Dipolog City, 7100 "Be and Do Much Better Each Day
R-eengineer for Tel No.: (065) 212-5843 with a
T-ransformation & e-mail address: zn.division@deped.gov.ph Sense of Urgency"
E-mpowerment

N-avigating "Be and Do Much N-avigating "Be and Do Much

Capitol Drive, O-pportunities to Capitol Drive,
O-pportunities to Better Each Day Better Each Day
Estaka, Dipolog Estaka, Dipolog
R-eengineer for with a R-eengineer for with a
City, 7100 City, 7100
T-ransformation & Sense of Urgency" T-ransformation & Sense of Urgency"
E-mpowerment Tel No.: E-mpowerment Tel No.:
(065) 212- (065) 212-
5843 5843
e-mail e-mail
address: address:
zn.division zn.division
@deped.gov. @deped.gov.
ph ph