Returning Aklanons

Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD

Returning Aklanons Provincial Government of Aklan

-- Please read before proceeding --

In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you will be providing in this
form shall not be used for other purposes except for COVID-19 contact-tracing activities.

control no.2d9d7020-1044-42ee-b5d2-3a66da9ac2b6 Arrival Date (mm-dd-yyyy) : 10-10-2021

Email: nabasmdrrmo@gmail.com Contact No.: 09705109996

Passport No/Valid ID Type & No : CRN 0111 2707386 7

First Name Middle Name Last Name
Name THELMA G CAHUYONG
Nationality : FILIPINO Sex: Female Birthdate (mm-dd-yyyy) : 02-27-1957

Place of Origin: MANILA CITY Destination/Hotel Name: NABAS AKLAN

Flight/Bus Number/Vessel Name: PAL Seat No.: PASSENGER

Street No. and Name of Street ( If applicable, indicate name of barangay)
Residence ALIMBO BAYBAY
Address Municipality/City: Province: Region:
(Philippines) NABAS AKLAN 6
Country(ies) worked, visited and transited in the last 30 days.

NONE

HEALTH PROFILE
1. Have you been sick (cough, difficulty breathing, colds, sore throat, fever) in the past 30
days?
[ ] Yes [ ] No
2. Have you been exposed to a confirmed case of COVID-19 ? [ ] Yes [ ] No
3. Have you been tested positive for COVID-19 using RT-PCR Test ? [ ] Yes [ ] No

Returning Aklanons
Upon submitting, I am providing consent to sharing my information for contact tracing
purposes, I confirm that the information I have given is true, correct and complete and that I
understand failure to answer any question may have serious consequences under Philippines
laws. (Article 171 and 172 of the Revised Penal Code of the Philippines)

2d9d7020-1044-42ee-b5d2-3a66da9ac2b6
Provincial Government of Aklan Signature

AkQuiRe 2021 ; Maintained by APICTO - 10/9/2021 8:04:43 AM