Department of Education

Region XII
CITY SCHOOLS DIVISION OF KORONADAL
Koronadal City

SELF DECLARATION OF HEALTH STATUS

Name of Activity: STEM Qualifying Examination

Date of Activity: July 12,2022
Venue: KNCHS Computer Lab room

● Name of Participant: Temperature: __________

Station/School: KNCHS
Contact Number:
Please answer truthfully the following:
1. I have been experiencing the following symptoms for the past 14 days
YES NO
a. colds
b. cough
c. fever
d. sorethroat or itchy throat
e. backpain
f. loss of sense of smell
g. loss of sense of taste
h. diarrhea
i. others: Pls specify symptom/s: _____________
2. I have been in contact with a symptomatic or confirmed case
of Covid-19 for the past 14 days.
3. I have a history of travel to other places outside of my place of
residence for the past 14 days.
If yes, specify date of travel: ___________________

place of travel: _________________________

4. I have a history of contact to people who came from other

countries or provinces
5. Please check:
I am fully vaccinated (2 doses)
I am partially vaccinated (only 1 dose)
I had my booster dose

I certify to the truthfulness of the above self-declaration.

Note: Data Privacy Policy will be observed Name & Signature