As part of the precautionary measures against COVID-19, kindly fill-out a declaration of your travel and health status.

This will be submitted by all individuals upon entering the campus.

PERSONAL INFORMATION
Please tick the appropriate box:
☐ Student ☐ Employee ☐ Visitor / Inquirer
Full Name (first name, middle name, last name): Contact Number:

Address:

For students, please indicate the following:

Grade / Year Track / Program
For visitors or inquirers, please indicate your organization’s name and address:

TRAVEL DECLARATION AND VISIT

INFORMATION
Please state the cities that you have visited in the past 14 days prior to this meeting/event and the dates of your travel.
Date of Entry Date of Exit
City (If outside the Philippines, include also in the list
(dd/mm/yyyy): (dd/mm/yyyy):
below)
1
2
OTHER DECLARATION
Please tick the box for each item YE NO
S
1 You or any member of your household / roommate have returned from
☐ ☐
foreign/local travel in the past 14 days prior to this date
2 You or any of member of your household / roommate are currently under a ☐ ☐
quarantine order
3 You have been in close contact with a confirmed COVID-19 patient within the ☐ ☐
past 14 days prior to this day
4 You are experiencing any of the following symptoms: ☐ ☐
a. Temperature of 37.6 degrees Celsius or higher
b. Dry cough ☐ ☐
c. Sore throat ☐ ☐
d. Runny nose ☐ ☐
e. Shortness of breath ☐ ☐
f. Headaches ☐ ☐
g. Gastrointestinal upset ☐ ☐
h. Lethargy / fatigue / tiredness / body aches ☐ ☐

Signature over printed name

PRIVACY NOTICE
In line with STI’s compliance with Data Privacy Act, any information declared in this form will be used solely for
evaluation and contract tracing on possible exposure to COVID-19.