Enclosure to DepEd-DOH Joint Memorandum Circular on the Operational Enclosure to DepEd-DOH Joint Memorandum Circular on the Operational

Guidelines on the Pilot Implementation of Face-to-face Learning Modality Guidelines on the Pilot Implementation of Face-to-face Learning Modality

Annex G: Annex G:
SAN JOSE ELEMENTARY HEALTH FORM SAN JOSE ELEMENTARY HEALTH FORM

I, _____________________________, declare that my entire household was I, _____________________________, declare that my entire household was
not considered a close contact, suspect, probable, or confirmed COVID- not considered a close contact, suspect, probable, or confirmed COVID-
19 case the past 14 days. Further, we do not experience any symptoms 19 case the past 14 days. Further, we do not experience any symptoms
related to COVID-19 such as: related to COVID-19 such as:
a) Fever a) Fever
b) Cough and colds b) Cough and colds
c) Difficulty of breathing c) Difficulty of breathing
d) Sore throat d) Sore throat
e) Diarrhea e) Diarrhea
f) Fatigue/ Tiredness f) Fatigue/ Tiredness
g) Headache g) Headache
h) Loss of taste or smell h) Loss of taste or smell
i) Body pains i) Body pains

I hereby certify that the information given is true, correct and complete.
I understand that any falsified 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 the date of accomplishment, following the
National Archives of the Philippines protocol.
I hereby certify that the information given is true, correct and complete.
I understand that any falsified 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 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 *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. to suspect that an individual may be infected after symptoms-based screening.