HEALTH DECLARATION FORM

HEALTH DECLARATION FORM

Name: ________________________________ Age/Sex: _____
Name: ________________________________ Age/Sex: _____
Address: _______________________________Date: _______
Address: _______________________________Date: _______
Contact Number: __
Contact Number: ________________________Time: _______
______________________Time: _______
Pls. check (√) if applicable:
Pls. check (√) if applicable:
1. Which of the following symptoms do you currently have?
1. Which of the following symptoms do you currently have?
FEVER COUGH TIREDNESS LBM
FEVER COUGH TIREDNESS LBM
COLDS HEADACHE SORETHROAT NONE
COLDS HEADACHE SORETHROAT NONE
OTHERS: _________________________________________
OTHERS: _________________________________________
2. For the past 2 weeks, did you have travel history from areas with
2. For the past 2 weeks, did you have travel history from areas with
local transmission? YES NO (if yes, pls indicate where)
local transmission? YES NO (if yes, pls indicate where)
___________________________________________
___________________________________________
3. This confirms that currently I am not identified as
3. This confirms that currently I am not identified as
PROBABLE/SUSPECT/PUM/CLOSE CONTACT TO CONFIRMED
PROBABLE/SUSPECT/PUM/CLOSE CONTACT TO CONFIRMED
CASES OF COVID-19.
CASES OF COVID-19.
I hereby declare that the above information I have provided is
I hereby declare that the above information I have provided is
accurate to my knowledge. I understand that I am responsible for
accurate to my knowledge. I understand that I am responsible for
any omission in disclosing vital information.
any omission in disclosing vital information.
I voluntarily and freely consent to the collection and sharing of
I voluntarily and freely consent to the collection and sharing of
the above personal information only in relation to DepEd Surigao del
the above personal information only in relation to DepEd Surigao del
Sur COVID-19 internal protocols and in accordance with the DATA
Sur COVID-19 internal protocols and in accordance with the DATA
PRIVACY ACT.
PRIVACY ACT.
I also commit to inform my superior about any symptoms that I
I also commit to inform my superior about any symptoms that I
might experience and/or may have contact with a CONFIRMED case
might experience and/or may have contactwith a CONFIRMED case
after signing this declaration.
after signing this declaration.
_________________________________
_________________________________
Signature Over Printed Name
Signature Over Printed Name

HEALTH DECLARATION FORM

HEALTH DECLARATION FORM
Name: ________________________________ Age/Sex: _____
Name: ________________________________ Age/Sex: _____
Address: _______________________________Date: _______
Address: _______________________________Date: _______
Contact Number: ________________________Time: _______
Contact Number: ________________________Time: _______
Pls. check (√) if applicable:
Pls. check (√) if applicable:
1. Which of the following symptoms do you currently have?
1. Which of the following symptoms do you currently have?
FEVER COUGH TIREDNESS LBM
FEVER COUGH TIREDNESS LBM
COLDS HEADACHE SORETHROAT NONE
COLDS HEADACHE SORETHROAT NONE
OTHERS: _________________________________________
OTHERS: _________________________________________
2. For the past 2 weeks, did you have travel history from areas with
2. For the past 2 weeks, did you have travel history from areas with
local transmission? YES NO (if yes, pls indicate where)
local transmission? YES NO (if yes, pls indicate where)
___________________________________________
___________________________________________
3. This confirms that currently I am not identified as
3. This confirms that currently I am not identified as
PROBABLE/SUSPECT/PUM/CLOSE CONTACT TO CONFIRMED
PROBABLE/SUSPECT/PUM/CLOSE CONTACT TO CONFIRMED
CASES OF COVID-19.
CASES OF COVID-19.
I hereby declare that the above information I have provided is
I hereby declare that the above information I have provided is
accurate to my knowledge. I understand that I am responsible for
accurate to my knowledge. I understand that I am responsible for
any omission in disclosing vital information.
any omission in disclosing vital information.
I voluntarily and freely consent to the collection and sharing of
I voluntarily and freely consent to the collection and sharing of
the above personal information only in relation to DepEd Surigao del
the above personal information only in relation to DepEd Surigao del
Sur COVID-19 internal protocols and in accordance with the DATA
Sur COVID-19 internal protocols and in accordance with the DATA
PRIVACY ACT.
PRIVACY ACT.
I also commit to inform my superior about any symptoms that I
I also commit to inform my superior about any symptoms that I
might experience and/or may have contactwith a CONFIRMED case
might experience and/or may have contact with a CONFIRMED case
after signing this declaration.
after signing this declaration.
_________________________________
_________________________________
Signature Over Printed Name
Signature Over Printed Name