Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

_______________________________________________________________________________ _______________________________________________________________________________

Enclosure to DepED-DOH Joint Memorandum Circular on the Operational Guidelines on the Pilot Implementation of Face- Enclosure to DepED-DOH Joint Memorandum Circular on the Operational Guidelines on the Pilot Implementation of Face-
to-face Learning Modality to-face Learning Modality

Annex G: Annex G:
HEALTH FORM HEALTH FORM

I, ________________________________________, declare that my entire household was not I, ________________________________________, declare that my entire household was not
considered a close contact, suspect, probably, or confirmed COVID-19 case in the past 14 days. considered a close contact, suspect, probably, or confirmed COVID-19 case in the past 14 days.
Further, we do not experience any symptoms related to COVID-19 such as: Further, we do not experience any symptoms related to COVID-19 such as:

a. Fever f. Fatigue/ Tiredness a.Fever f. Fatigue/ Tiredness

b. Cough & colds g. Headache b.Cough & colds g. Headache
c. Difficulty of breathing h. Loss of taste or smell c.Difficulty of breathing h. Loss of taste or smell
d. Sore throat I. Body pains d.Sore throat I. Body pains
e. Diarrhea e.Diarrhea

I hereby certify that the information given is true, correct & complete. I understand that any falsified I hereby certify that the information given is true, correct & complete. I understand that any falsified
response may have serious consequences.I understand that my personal information is protected response may have serious consequences.I understand that my personal information is protected
by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from
the date of accomplishment, following the National Archives of the Philippines protocol. the date of accomplishment, following the National Archives of the Philippines protocol.

______________________________________ ________________________________ ______________________________________ ________________________________

Name and Signature Date Name and Signature Date

* Per DOH DM 2020-0512, testing is performed when there is a particular reason to suspect that an individual * Per DOH DM 2020-0512, testing is performed when there is a particular reason to suspect that an individual
may be infected after symptoms-based screening. may be infected after symptoms-based screening.