Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

Region IX, Zamboanga Peninsula Region IX, Zamboanga Peninsula
SCHOOLS DIVISION OF ZAMBOANGA DEL SUR SCHOOLS DIVISION OF ZAMBOANGA DEL SUR
__________________________ _____________
Signature Date
Enclosure No. 2 to Division Memorandum No. ___, s. 2020
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.
HEALTH DECLARATION FORM

Date of Visit: __________ Time: _____________

Temperature: _________ Contact #: RESPONDENT INFORMATION
_______________________ Last Name:
First Name:
RESPONDENT INFORMATION
Middle
Last Name: Name:
First Name: Sex: Male Nationality:
Middle Age: Female
Name:
Sex: Male 2 School/District:
Age: Female ______________________________________
Address: Barangay:
School/District: _____________________________ City/Municipality:
_________________._____________________ _____________________________
Address: Barangay: Province: __________________ Region:
_____________________________ City/Municipality: _________
_____________________________ Purpose of Visit:
Province: __________________ Region: 1. In the past 14 days, which of the following symptom(s) have you
_________ experienced. Please check () the relevant box(es).
Purpose of Visit:
1. In the past 14 days, which of the following symptom(s) have you Fever
experienced. Please check () the relevant box(es).
Sore throat
Diarrhea
Fever Body aches
Sore throat Headache
Diarrhea Dry Cough
Body aches Tiredness
Headache Shortness of breath
Dry Cough Runny Nose
Tiredness Others
Shortness of breath NONE OF THE ABOVE
Runny Nose
2. Have you been in contact with a confirmed COVID-19 patient in
Others the past 14 days?
NONE OF THE ABOVE
2. Have you been in contact with a confirmed COVID-19 patient in Yes No
the past 14 days? 3. Have you been identified to high risk areas of COVID-19 in the
past 14 days?
Yes No
3. Have you been identified to high risk areas of COVID-19 in the Yes No
past 14 days? If yes, please indicate the area(s):
Declaration and Data Privacy Consent Form:
Yes No
If yes, please indicate the area(s): The information I have given is true, correct and complete. I understand that
Declaration and Data Privacy Consent Form: failure to answer any question or giving false answer can be penalized in
accordance with law.
The information I have given is true, correct and complete. I understand that
failure to answer any question or giving false answer can be penalized in
accordance with law.
I voluntarily and freely consent to the collection and sharing of the above
personal information only in relation to the DepEd Dipolog Ciy, Zambaoanga
del Norte COVID-19 internal protocols.
I voluntarily and freely consent to the collection and sharing of the above
personal information only in relation to the DepEd Dipolog Ciy, Zambaoanga __________________________ _____________
del Norte COVID-19 internal 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.
 N-avigating
O-pportunities to Capitol Drive, Estaka, Dipolog City, 7100 "Be and Do Much Better Each Day
R-eengineer for Tel No.: (065) 212-5843 with a
T-ransformationRepublic
& of the Philippines Republic Sense
of the Philippines
of Urgency"
e-mail address: zn.division@deped.gov.ph Department of Education
E-mpowermentDepartment of Education
Region IX, Zamboanga Peninsula Region IX, Zamboanga Peninsula
SCHOOLS DIVISION OF ZAMBOANGA DEL SUR SCHOOLS DIVISION OF ZAMBOANGA DEL SUR

Enclosure No. 2 to Division Memorandum No. ___, s. 2020

HEALTH DECLARATION FORM
Date of Visit: _________________ Time:
____________
Temperature: _________ Contact #:
_________________