Date: ____________ Logbook No.

: _________ Temperature: _________°C Signature Date

Name Name

Age/Sex School Teniapan NHS Age/Sex School Teniapan NHS

Employee ID Employee ID
District: San Pablo 1 District: San Pablo 1
No. No.
Office to Office to
Transact Transact
Purpose Purpose
DECLARATION DECLARATION
I am free of COVID-19 symptoms (or have confirmed my symptoms I am free of COVID-19 symptoms (or have confirmed my symptoms
are not COVID-19 related) including the following: are not COVID-19 related) including the following:
- Loss of sense of smell or taste - Sore throat - Loss of sense of smell or taste - Sore throat
- Fever - Colds/Runny nose - Fever - Colds/Runny nose
- Cough - Shortness of breath - Cough - Shortness of breath

I have not been in contact with a Suspect, Probable or Confirmed I have not been in contact with a Suspect, Probable or Confirmed
case of COVID-19 in the last 14 days. case of COVID-19 in the last 14 days.

I am not currently directed to isolate or quarantine. I am not currently directed to isolate or quarantine.
I have not travelled to high-risk areas outside of the province
province. I have not travelled to high-risk areas outside of the province.

Declaration and Data Privacy Consent Form:
I certify that the above information given is true, correct and complete. I
acknowledge and understand that giving false information is punishable by law.
I voluntarily and freely consent to the collection and sharing of the above personal
information only in relation to the DepEd-Zamboanga del Sur COVID-19
protocols.
__________________________ _____________
Signature Date
Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.
Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.
Date: ____________ Logbook No.: _________ Temperature: _________°C
Declaration and Data Privacy Consent Form:
I certify that the above information given is true, correct and complete. I
acknowledge and understand that giving false information is punishable by law.
I voluntarily and freely consent to the collection and sharing of the above personal
information only in relation to the DepEd-Zamboanga del Sur COVID-19
protocols.
__________________________ _____________
Signature Date
Please be advised that the above information shall only be used in relation to

Name Name

Age/Sex School Teniapan NHS Age/Sex School Teniapan NHS

Employee ID Employee ID
District: San Pablo 1 District: San Pablo 1
No. No.
Office to Office to
Transact Transact
Purpose Purpose

DECLARATION DECLARATION
I am free of COVID-19 symptoms (or have confirmed my symptoms I am free of COVID-19 symptoms (or have confirmed my symptoms
are not COVID-19 related) including the following: are not COVID-19 related) including the following:
- Loss of sense of smell or taste - Sore throat - Loss of sense of smell or taste - Sore throat
- Fever - Colds/Runny nose - Fever - Colds/Runny nose
- Cough - Shortness of breath - Cough - Shortness of breath

I have not been in contact with a Suspect, Probable or Confirmed I have not been in contact with a Suspect, Probable or Confirmed
case of COVID-19 in the last 14 days. case of COVID-19 in the last 14 days.

I am not currently directed to isolate or quarantine. I am not currently directed to isolate or quarantine.

I have not travelled to high-risk areas outside of the province. I have not travelled to high-risk areas outside of the province.
Date: ____________ Logbook No.: _________ Temperature: _________°C DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.

Declaration and Data Privacy Consent Form:

I certify that the above information given is true, correct and complete. I
acknowledge and understand that giving false information is punishable by law.
I voluntarily and freely consent to the collection and sharing of the above personal
information only in relation to the DepEd-Zamboanga del Sur COVID-19
protocols.
Date: ____________ Logbook No.: _________ Temperature: _________°C
Declaration and Data Privacy Consent Form:
I certify that the above information given is true, correct and complete. I
acknowledge and understand that giving false information is punishable by law.

__________________________ _____________
I voluntarily and freely consent to the collection and sharing of the above personal
information only in relation to the DepEd-Zamboanga del Sur COVID-19
protocols.

__________________________ _____________
Signature Date
Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.