Health Declaration Form Health Declaration Form

Date: 10/05/2021 Date: 10/05/2021

Temperature: ________ Temperature: ________
Name: CLARIZEL OROGO QUISAO Name: ANTHONY CORONADO QUISAO
Age: 30 Sex: FEMALE Age: 31 Sex: MALE
School: AYUSAN ELEMENTARY SCHOOL School: AYUSAN ELEMENTARY SCHOOL
Contact Number: 0951-721-0077 Contact Number: 0912-599-5541
Office to Visit: _________________________________ Office to Visit: _________________________________
E. SIGNS AND SYMPTOMS 3 DAYS AGO Oo Hindi G. SIGNS AND SYMPTOMS 3 DAYS AGO Oo Hindi
19. Fever / 28. Fever /
20. Cough / 29. Cough /
21. Colds / 30. Colds /
22. Sore throat / 31. Sore throat /
23. Loss of taste / 32. Loss of taste /
24. Loss of smell / 33. Loss of smell /
25. Chest pain / 34. Chest pain /
26. Difficulty of breathing / 35. Difficulty of breathing /
27. Others__________________ 36. Others__________________

F. TRAVEL HISTORY 3 DAYS AGO H. TRAVEL HISTORY 3 DAYS AGO

7. Inside Quezon / 10. Inside Quezon /

8. Outside Quezon / 11. Outside Quezon /
9. Travel Abroad / 12. Travel Abroad /
I hereby authorize DepEd Quezon to collect and process the data I hereby authorize DepEd Quezon to collect and process the data
indicated herein for the purpose of effecting control of the COVID-19 indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA infection. I understand that my personal information is protected by RA
10173, Data Privacy Act of 2012, and that I am required by RA 11469, 10173, Data Privacy Act of 2012, and that I am required by RA 11469,
Bayanihan to Heal as One Act to provide truthful information. Bayanihan to Heal as One Act to provide truthful information.

Signature:________________________________ Signature:________________________________

Health Declaration Form Health Declaration Form

Date: _______________ Date: _______________
Temperature: ________ Temperature: ________
Name: ________________________________________ Name: ________________________________________
Age: ______ Sex: ______ Age: ______ Sex: ______
School:________________________________________ School:________________________________________
Contact Number: _____________________ Contact Number: _____________________
Office to Visit: _________________________________ Office to Visit: _________________________________
C. SIGNS AND SYMPTOMS 3 DAYS AGO Oo Hindi A. SIGNS AND SYMPTOMS 3 DAYS AGO Oo Hindi
10. Fever 1. Fever
11. Cough 2. Cough
12. Colds 3. Colds
13. Sore throat 4. Sore throat
14. Loss of taste 5. Loss of taste
15. Loss of smell 6. Loss of smell
16. Chest pain 7. Chest pain
17. Difficulty of breathing 8. Difficulty of breathing
18. Others__________________ 9. Others__________________

D. TRAVEL HISTORY 3 DAYS AGO B. TRAVEL HISTORY 3 DAYS AGO

4. Inside Quezon 1. Inside Quezon

5. Outside Quezon
6. Travel Abroad
I hereby authorize DepEd Quezon to collect and process the data
indicated herein 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 2012, and that I am required by RA 11469,
Bayanihan to Heal as One Act to provide truthful information.
2. Outside Quezon
3. Travel Abroad
I hereby authorize DepEd Quezon to collect and process the data
indicated herein 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 2012, and that I am required by RA 11469,
Bayanihan to Heal as One Act to provide truthful information.

Signature:________________________________ Signature:________________________________