“For your own protection, forthe safety of your fay and the community” Cty of Peri Princess HEALTH DECLARATION CHECKLIST ‘ive ito lease ice coun a ans Portof Origin: Fie Seat Arr Port of Origin: Fit Seat Cou nts visted ore past wo (2) weeks and ay of ai ‘Name Fit Name: ‘Middle Name Nationality: il Status: linle or nursing home Destination and accommodation (Fortourist only ‘adress (For Locale Fel/ Mobile no. of passenger. 23 person currentl having fever, cough and/or respiratory problems? ‘Did you take antifever medication during the last 4-6 hours? a ~+ Did you have any contact with a suspected 2019-nCoV patient? a ‘Name and Signature of Passenger TO BE GIVEN TO BUREAU OF QUARANTINE REPRESENTATIVE Note: i you have been to 2 known 2019:nCoV affected countries: Center for Health Development (CHD) MIMAROPA HEMS Ospital ng Palawan ~ Emergency Department 3f Health Office (PDOHO) Bureau of Quarantine City Health office Patrolon ‘Adventist Hospital Palawan MMG-PPC Cooperative Hospital + (463) 48-434-1760 Personal Data Name: ast Name First Name Sex:__Age:__ Nationality: iMidale Name v. Development {CHD} [CG Department Head City Health Officer Puerto Princesa City = FOR PASSENGER USE.