Republic of the Philippines

LEYTE NORMAL UNIVERSITY

Tacloban City

STUDENT INFORMATION FORM

Dear Students:

Relative to the COVID-19 pandemic, please fill out this form as honestly and
accurately as possible and submit it to Mr. Andrew Siguan on or before April 24, 2020 thru
email, messenger or text message SO YOU CAN ENTER THE UNIVERSITY UPON RESUMPTION
OF CLASSES. Thank you very much for your cooperation!

LNU Administration
PERSONAL DATA
Name : LABOGA, KEZIAH GENE R.
(Family Name/First Name/Middle Name)
DEGREE PROGRAM : Bachelor of Physical Education
Year Level :I
Section : EP1-2
Student Number : 1904642
Mobile Number : 09384769714
Email Address : keziahgenelaboga07@gmail.com
Facebook Name : Keziah gene R. Laboga
Father’s Name : Joselito B. Laboga
Mother’s Name : Jennifer R. Laboga

Contact Number of Parent/Guardian: 09102544042

Complete Home Address: Brgy. Borseth Alangalang Leyte

TRAVEL HISTORY BOTH LOCAL AND INTERNATIONAL FOR THE LAST 3 MONTHS
(start from the most recent and feel free to add space if necessary)

Name of place visited: NA

Travel period: NA

Name of place visited: NA

Travel period: NA

Name of place visited: NA

Travel period: NA

MEDICAL HISTORY
Are you experiencing or suffering from any of the following within the last 14 days?
Cough (yes/no)
Fever (yes/no)
Difficulty in breathing (yes/no)
Diarrhea (yes/no)
Colds (yes/no)
Others: Please Specify: _________________________________________________

EXPOSURE TO OR CONTACT WITH THE FOLLOWING PERSONS:

COVID-19 Suspect (Yes/No), Probable (Yes/No), Confirmed (Yes/No)

CONSIDERED as COVID-19 Suspect (Yes/No), Probable (Yes/No), Confirmed (Yes/No)

Other Details: ______________________________________________________________________
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In my honor, I hereby declare that the above information are true and correct and I am fully
aware that these will be used by the LNU administration relative to their preparation for the resumption
of classes.
SO HELP US GOD!!!
KEZIAH GENE R. LABOGA
Signature over Printed Name of Student