VISITOR HEALTH DECLARATION FORM

Name: ____________________________ Sex: _____ Age: _____ Temperature: ______

Residence: ________________________________________________
Contact Number: ____________________
YES
NO
1.Are you experiencing any of the following symptoms?
a. Fever
b. Cough
c. Colds
d. Diarrhea
e. Sore Throats
f. Shortness of breath
2. Close contact with COVID-19 case?
3. Have you contact with COVID-19 suspect case?
4. Have you any contact with anyone with fever, cough,
colds, or sore throat in the last two weeks?
5. Have you travelled outside of the Philippines in the last 14 days?
Where:__________________________
Date:____________________________
6. Have you travelled to any area outside youre province?
Where:_______________________
Date:________________________

I hereby authorize Deped Misamis Oriental to collect and process the data indicated here in for the
purpose of effecting control of the COVID-19 infection. I understand that my personal information is
protected by RA 10173, Data Privacy Act of 2012 that I am required by RA 11469, Bayanihan to heal
as One Act, to provide truthful information.

Signature:______________________ Date: _____________

Time:____________

VISITOR HEALTH DECLARATION FORM

Name: ____________________________ Sex: _____ Age: _____ Temperature: ______

Residence: ________________________________________________
Contact Number: ____________________
YES
NO
1.Are you experiencing any of the following symptoms?
a. Fever
b. Cough
c. Colds
d. Diarrhea
e. Sore Throats
f. Shortness of breath
2. Close contact with COVID-19 case?
3. Have you contact with COVID-19 suspect case?
4. Have you any contact with anyone with fever, cough,
colds, or sore throat in the last two weeks?
5. Have you travelled outside of the Philippines in the last 14 days?
Where:__________________________
Date:____________________________
 6. Have you travelled to any area outside youre province?
Where:_______________________
Date:________________________

I hereby authorize Deped Misamis Oriental to collect and process the data indicated here in for the
purpose of effecting control of the COVID-19 infection. I understand that my personal information is
protected by RA 10173, Data Privacy Act of 2012 that I am required by RA 11469, Bayanihan to heal
as One Act, to provide truthful information.

Signature:______________________ Date: _____________

Time:____________