Date Today :_______________

HEALTH DECLARATION FORM

In line with the Workplace Prevention and Control of COVID-19, students are required to accomplish the health symptoms questionaire daily & prior to entry. Please fill in HONESTLY and
COMPLETELY and drop it in the DROP BOX.
Student Full Name:
Visitor Last Name First name Middle Name
Residence Address: Age:______ Sex:_______ Temp:_____________
YES
Kindly check underNO
the
YES
and NO Column for your
answer
a.Sore Throat
(pananakit ng lalamunan)
1. Are you
b. Body Pains
experiencing:
(Pananakit ng Katawan)
C. Headache
(Pananakit ng Ulo)
d. Fever for the past few days
(Lagnat sa nakalipas na mga araw)
2. Have you worked together or stayed in the same close environment or a confirmed COVID-19 case?
(May nakasama o nakatrabahong tao na kumpirmadong may COVID-19 o may impeksyon ng corona virus)
3. Have you had contact with anyone with fever, cough, colds and sore throat for the past 14 Days?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
4. Have you travelled to any area with positive COVID-19 case?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
5. Have you ever travelled outside the Philippines in the last 14 days?
(Ikaw ba ay nakabiyahe sa labas ng Bansa sa nakalipas na 14 na araw?
Certification and Data Privacy Consent
I certify that the information I provided is true, correct and complete, I hereby authorize the Iligan Computer Institute
to collect and process the information indicated herein, in accordance with applicable laws and regulations, for the purpose of affecting control of the
COVID-19 infection.

Name and Signature Cellphone Number: _________________

Date Today :_______________

In line with the Workplace Prevention and Control of COVID-19, students are required to accomplish the health symptoms questionaire daily & prior to entry. Please fill in HONESTLY and
COMPLETELY and drop it in the DROP BOX.
Student
Full Name:
Visitor Last Name First name Middle Name
Residence Address: Age:______ Sex:_______ Temp:_____________
YES
Kindly check underNO
the
YES
and NO Column for your
answer
a.Sore Throat
(pananakit ng lalamunan)
1. Are you
experiencing: b. Body Pains
(Pananakit ng Katawan)
C. Headache
(Pananakit ng Ulo)
d. Fever for the past few days
(Lagnat sa nakalipas na mga araw)
2. Have you worked together or stayed in the same close environment or a confirmed COVID-19 case?
(May nakasama o nakatrabahong tao na kumpirmadong may COVID-19 o may impeksyon ng corona virus)
3. Have you had contact with anyone with fever, cough, colds and sore throat for the past 14 Days?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
4. Have you travelled to any area with positive COVID-19 case?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
5. Have you ever travelled outside the Philippines in the last 14 days?
(Ikaw ba ay nakabiyahe sa labas ng Bansa sa nakalipas na 14 na araw?
Certification and Data Privacy Consent
I certify that the information I provided is true, correct and complete, I hereby authorize the Iligan Computer Institute
to collect and process the information indicated herein, in accordance with applicable laws and regulations, for the purpose of affecting control of the
COVID-19 infection.
Name and Signature Cellphone Number: _________________