Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

REGION VI – WESTERN VISAYAS REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF HIMAMAYLAN CITY SCHOOLS DIVISION OF HIMAMAYLAN CITY

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

DATE & TIME: DATE & TIME:

NAME: NAME:
OFFICE OFFICE
CONTACT NO.: CONTACT NO.:
TEMPERATURE: TEMPERATURE:

Instruction: Please put MARK ( / ) YES NO Instruction: Please put MARK ( / ) YES NO
1. Are you experiencing: 1. Are you experiencing:
a. Sore Throat a. Sore Throat
b. Body Pains b. Body Pains
c. Headache c. Headache
d. Fever for the past few days d. Fever for the past few days
2. Have you worked together or stayed in 2. Have you worked together or stayed in
the same close environment of the same close environment of
confirmed COVID-19 cases? confirmed COVID-19 cases?
3. Have you had any contact with anyone 3. Have you had any contact with anyone
with fever, cough, colds, and sore with fever, cough, colds, and sore
throat in the past 2 weeks? throat in the past 2 weeks?
4. Have you travelled to places outside 4. Have you travelled to places outside
Himamaylan City in the past 14 days? If Himamaylan City in the past 14 days? If
Yes where? _____________________ Yes where? _____________________
I hereby authorize DepEd-SDO Himamaylan city, to collect and process the date I hereby authorize DepEd-SDO Himamaylan city, to collect and process the date
indicated herein for the purpose of effecting control of COVID-19 infection. I indicated herein for the purpose of effecting control of COVID-19 infection. I
understand that my personal information is protected by RA 10173, Data Privacy understand that my personal information is protected by RA 10173, Data Privacy
Act of 2012, and I am required by RA 11469, Bayanihan to Heal as one Act, to Act of 2012, and I am required by RA 11469, Bayanihan to Heal as one Act, to
provide truthful information. provide truthful information.

_______________________________ _______________________________
Signature over Printed Name Signature over Printed Name

Republic of the Philippines Republic of the Philippines

Department of Education Department of Education
REGION VI – WESTERN VISAYAS REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF HIMAMAYLAN CITY SCHOOLS DIVISION OF HIMAMAYLAN CITY

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

DATE & TIME: DATE & TIME:

NAME: NAME:
OFFICE OFFICE
CONTACT NO.: CONTACT NO.:
TEMPERATURE: TEMPERATURE:

Instruction: Please put MARK ( / ) YES NO Instruction: Please put MARK ( / ) YES NO
1. Are you experiencing: 1. Are you experiencing:
a. Sore Throat a. Sore Throat
b. Body Pains b. Body Pains
c. Headache c. Headache
d. Fever for the past few days d. Fever for the past few days
2. Have you worked together or stayed in 2. Have you worked together or stayed in
the same close environment of the same close environment of
confirmed COVID-19 cases? confirmed COVID-19 cases?
3. Have you had any contact with anyone 3. Have you had any contact with anyone
with fever, cough, colds, and sore with fever, cough, colds, and sore
throat in the past 2 weeks? throat in the past 2 weeks?
4. Have you travelled to places outside 4. Have you travelled to places outside
Himamaylan City in the past 14 days? If Himamaylan City in the past 14 days? If
Yes where? _____________________ Yes where? _____________________
I hereby authorize DepEd-SDO Himamaylan city, to collect and process the date I hereby authorize DepEd-SDO Himamaylan city, to collect and process the date
indicated herein for the purpose of effecting control of COVID-19 infection. I indicated herein for the purpose of effecting control of COVID-19 infection. I
understand that my personal information is protected by RA 10173, Data Privacy understand that my personal information is protected by RA 10173, Data Privacy
Act of 2012, and I am required by RA 11469, Bayanihan to Heal as one Act, to Act of 2012, and I am required by RA 11469, Bayanihan to Heal as one Act, to
provide truthful information. provide truthful information.

_______________________________ _______________________________
Signature over Printed Name Signature over Printed Name