LEYTE NORMAL UNIVERSITY HEALTH DECLARATION FORM ver. 2.

Notice: For the safety of your family, the LNU Community and yourself, please
accomplish this form honestly and completely.

HEALTH DECLARATION FORM ver. 2.0

PERSONAL DATA STUDENT NO. ______________
Notice: For the safety of your family, the LNU Community and yourself, please Name: _______________________________________________
accomplish this form honestly and completely. Last Name First Name Middle Name

Age:_______ Sex:____________ Civil Status:_______________

PERSONAL DATA STUDENT NO. ______________
Name: _______________________________________________
Last Name First Name Middle Name
Age:_______ Sex:____________ Civil Status:_______________
Grade/Program/Year-Section: ____________________________ Permanent
Address:____________________________________ Current Address while
Attending School:____________________
____________________________________________________
[ ]School Dormitory [ ]Boarding House [ ]Relative’s House
[ ]Apartment House [ ]Family-owned house
[ ]Others (please specify):_____________________________
Contact No.:__________________________________________
Contact in case of Emergency:
____________________________________________________
Contact No.:__________________________________________
TRAVEL HISTORY
Countries/Provinces/Cities/Municipalities visited for the past four (4) weeks (include dates
covered): _________________________________
__________________________________________________________
Flight No./Airline:_____________________________________________
Date and Time of Arrival in Tacloban City:_________________________
Grade/Program/Year-Section: ____________________________ Permanent
Address:____________________________________ Current Address while
Attending School:____________________
____________________________________________________
[ ]School Dormitory [ ]Boarding House [ ]Relative’s House
[ ]Apartment House [ ]Family-owned house
[ ]Others (please specify):_____________________________
Contact No.:__________________________________________ Person to
Contact in case of Emergency:
____________________________________________________
Contact No.:__________________________________________
Person to
TRAVEL HISTORY
Countries/Provinces/Cities/Municipalities visited for the past four (4) weeks (include dates
covered): _________________________________
__________________________________________________________
Flight No./Airline:_____________________________________________
Date and Time of Arrival in Tacloban City:_________________________
EXPOSURE HISTORY
Have you been in close contact with a suspected/probable/confirmed case of
Coronavirus Disease 2019 (COVID)-19 in the past fourteen (14) days:
[ ]No [ ]Yes, Describe circumstance:_________________________

EXPOSURE HISTORY Were you identified as PUM/PUI/Suspect/Probable/Confirmed case of COVID-19 by

Have you been in close contact with a suspected/probable/confirmed case of your community at present or during the community quarantine period?
Coronavirus Disease 2019 (COVID)-19 in the past fourteen (14) days: [ ]No [ ]Yes, Describe circumstance:__________________________ If yes, please
[ ]No [ ]Yes, Describe circumstance:_________________________ submit Quarantine Clearance upon registration.

Were you identified as PUM/PUI/Suspect/Probable/Confirmed case of COVID-19 by MEDICAL HISTORY

your community at present or during the community quarantine period? Please check ( / ) if you have been diagnosed with the following illnesses: [ ]Hypertension
[ ]No [ ]Yes, Describe circumstance:__________________________ If yes, please [ ]Diabetes Mellitus [ ]Bronchial Asthma
submit Quarantine Clearance upon registration. [ ]Others (please specify): _____________________________________

MEDICAL HISTORY Please check ( / ) if you have any of the following symptoms at present or during the past
Please check ( / ) if you have been diagnosed with the following illnesses: 14 days:
[ ]Hypertension [ ]Diabetes Mellitus [ ]Bronchial Asthma [ ]Fever [ ]Cough [ ]Sore Throat
[ ]Others (please specify): _____________________________________ [ ]Headache [ ]Colds [ ]Difficulty of Breathing
[ ]Abdominal Pain [ ]Diarrhea [ ]Vomiting
Please check ( / ) if you have any of the following symptoms at present or during the past [ ] Others (please specify): ____________________________________
14 days:
[ ]Fever [ ]Cough [ ]Sore Throat I declare all the information provided in this form are true and correct.
[ ]Headache [ ]Colds [ ]Difficulty of Breathing
[ ]Abdominal Pain [ ]Diarrhea [ ]Vomiting Signature:_________________________ Date:_____________
[ ] Others (please specify): ____________________________________ ……………………………………………………………………………………..
(Please do not fill out this portion, for checker only)
I declare all the information provided in this form are true and correct.

Temperature: _________°C
Signature:_________________________ Date:_____________ Quarantine Clearance: [ ]With [ ]Without [ ]N/A
…………………………………………………………………………………….. Certification attesting that the bearer is neither a Suspected,
(Please do not fill out this portion, for checker only) Probable, nor Confirmed COVID-19 Case: [ ]With [ ]Without [ ]N/A

Temperature: _________°C
Quarantine Clearance: [ ]With [ ]Without [ ]N/A Checked by: ____________________________ Date: _____________
Certification attesting that the bearer is neither a Suspected, (Name & Signature)
Probable, nor Confirmed COVID-19 Case: [ ]With [ ]Without [ ]N/A
Disposition: [ ]Cleared [ ]Referred to HSO Medical Clinic
……………………………………………………………………………………..
Checked by: ____________________________ Date: _____________ (Please do not fill out this portion, for HSO Medical Clinic Staff only)
(Name & Signature)

Final Disposition: [ ]Cleared [ ]For Home Quarantine [ ]Referred

Disposition: [ ]Cleared [ ]Referred to HSO Medical Clinic
[ ]To Be Sent Home [ ]Others:_________________
……………………………………………………………………………………..
(Please do not fill out this portion, for HSO Medical Clinic Staff only)

Assessed by: ____________________________ Date: _____________

Final Disposition: [ ]Cleared [ ]For Home Quarantine [ ]Referred (Name & Signature)
[ ]To Be Sent Home [ ]Others:_________________
STATEMENT OF PRIVACY. All information collected will be for the sole purpose of prevention,
mitigation and management of COVID-19 pandemic. Your personal information maybe shared to the
Assessed by: ____________________________ Date: _____________ Department of Health for the same purpose. Your personal information and identity in particular is
protected under Data Privacy Act of
(Name & Signature)
2012.

STATEMENT OF PRIVACY. All information collected will be for the sole purpose of prevention,
mitigation and management of COVID-19 pandemic. Your personal information maybe shared to the
Department of Health for the same purpose. Your personal information and identity in particular is
protected under Data Privacy Act of 2012.

LEYTE NORMAL UNIVERSITY