Scribd
Upload
59 views3 pages

Visitor Health Declaration Form

The visitor health declaration form collects personal information such as name, age, temperature, residence, and contact number. It asks a series of yes or no questions regarding COVID-19 symptoms, close contact with COVID-19 cases, travel history, and contact with others exhibiting symptoms. By signing, the visitor authorizes the organization to collect and process this health data to control the spread of COVID-19, and acknowledges their requirement to provide truthful information according to relevant acts.

Uploaded by

Gena Fe L. Jagus
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
59 views3 pages

Visitor Health Declaration Form

The visitor health declaration form collects personal information such as name, age, temperature, residence, and contact number. It asks a series of yes or no questions regarding COVID-19 symptoms, close contact with COVID-19 cases, travel history, and contact with others exhibiting symptoms. By signing, the visitor authorizes the organization to collect and process this health data to control the spread of COVID-19, and acknowledges their requirement to provide truthful information according to relevant acts.

Uploaded by

Gena Fe L. Jagus
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

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
d. Colds
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 your 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 2012that I am required by RA 11469, Bayanihan to heal as One Act, to provide truthful information.

Signature: _________________________ Date: ________________ Time: ___________


Purpose: _______________________________________________________________________________________

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
d. Colds
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 your 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 2012that I am required by RA 11469, Bayanihan to heal as One Act, to provide truthful information.

Signature: _________________________ Date: ________________ Time: ___________


Purpose: _______________________________________________________________________________________

You might also like