Republic of the Philippines

COMMISSION ON ELECTIONS
Office of the Election Officer
Baguio City

HEALTH DECLARATION FORM

APPLICANT PROFILE
Name:
(Last Name, First Name, Middle Name)
Birthday : Age: Sex: ( ) Male
(mm/dd/yyyy) ( ) Female
Occupation: Civil Status: Nationality:

PHILIPPINE RESIDENCE
Address:
( House No./Lot/Bldg., Street, Barangay, Municipality/City, Province )
Tel. No.: Cellphone No.: Email add.:

Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence outside the Philippines

Employer's Name: Occupation: Place of Work:

Address:
( House No./Lot/Bldg., Street, Barangay, Municipality/City, Province, Country )
Office Phone No: Cellphone No.:
TRAVEL HISTORY

History of travel/visit/work in other countries with a known COVID-19 transmission: ( ) Yes ( ) No

Port (Country of Exit): Airline/Sea Vessel:

Flight/Vessel No.: Date of Departure: Date of Arrival (Phils.)
EXPOSURE HISTORY
History of Exposure to known ( ) Yes If yes: Date of contact with known COVID-
COVID-19 to case ( ) No 19 CASE: (mm/dd/yyyy)
( ) Unknown
Have you been in a place with a ( ) Yes If yes: ( ) Work Place
known COVID-19 transmission: ( ) No (Place) ( ) Social gathering
( ) Unknown ( ) Health facility
( ) Religious gathering
( ) Others: specify type: ____________________
If Yes: Date when you have been in that place: Name of the Place: _______________
(mm/dd/yyyy)

Name Contact Number

List the names of persons who were with you during this/these
1
occasion(s) and their contact numbers:
2
(Use back part of this sheet when neccessary)
3
Are you a confirmed case of COVID-19 (Coronavirus). ( ) Yes ( ) No

Are you suffering from any of the following flu-like symptoms (or in the last 48 hours), which may
include: Fever, Cough, Sore-throat, Running nose or Stuffy nose, Headache, Aches and pains, ( ) Yes ( ) No
Fatigue, Breathing difficulty, or any other symptoms (i.e. gastroenteritis related or similar)

I declare that all the information given in this form is true and correct:

(Date) (Signature over Printed Name of Applicant)