Republic of the Philippines

Department of Education
Schools Divisioin of Biliran
NAVAL NATIONAL HIGH SCHOOL
Naval, Biliran

HEALTH DECLARATION FORM

#COVID-19
Date: _________________
Important: Per Presidential Proclamation No. 922 dated March 8, 2020 “Declaring a State of Public Health Emergency throughout the Philippines”, and to prevent further transmission
of the Corona Virus Disease-2019 (COVID-19), may we request you to fill-up this Health Declaration for future contact tracing purposes; rest assured that the information given be
treated with utmost confidentiality in accordance with the Republic Act No. 10173 or the “Data Privacy Act.” Thank you.
NavalNHS Management

Note: Fill-up as required. Enter N/A, if not applicable. Do not leave any blank. Please write legibly.

Name : __________________________________________ Gender (Sex) : ___________________________

Date of Birth : ___________________________ Civil Status : ___________________________
Occupation : ___________________________ Contact No. : ___________________________
Complete Address :
_______________________________________________________________________________________________________________________

Place(s) within the Philippines that you have visited in the last fourteen (14) days:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Have you been sick of any of the following in the last 14 days? Please check: __________ YES ___________ NO
_____Fever _____Cough _____Colds _____Difficulty in Breathing _____ Diarrhea _____Sore Throat

Declaration: I hereby certify that the above information is true and complete. I understand that my failure to answer, or any false information or misleading information given by me
may be used as a ground for the filing of case(s) against me under Article 171 and 172 of the Revised Penal Code of the Philippines, or Republic Act No. 11332, otherwise known as
the “Mandatory Reporting of Notifiable Diseases and Health Events of Public Concern Act.”

_______________________________________
Signature over Printed Name

Republic of the Philippines

Department of Education
Schools Divisioin of Biliran
NAVAL NATIONAL HIGH SCHOOL
Naval, Biliran

HEALTH DECLARATION FORM

#COVID-19
Date: _________________
Important: Per Presidential Proclamation No. 922 dated March 8, 2020 “Declaring a State of Public Health Emergency throughout the Philippines”, and to prevent further transmission
of the Corona Virus Disease-2019 (COVID-19), may we request you to fill-up this Health Declaration for future contact tracing purposes; rest assured that the information given be
treated with utmost confidentiality in accordance with the Republic Act No. 10173 or the “Data Privacy Act.” Thank you.
NavalNHS Management

Note: Fill-up as required. Enter N/A, if not applicable. Do not leave any blank. Please write legibly.

Name : __________________________________________ Gender (Sex) : ___________________________

Date of Birth : ___________________________ Civil Status : ___________________________
Occupation : ___________________________ Contact No. : ___________________________
Complete Address :
_______________________________________________________________________________________________________________________

Place(s) within the Philippines that you have visited in the last fourteen (14) days:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Have you been sick of any of the following in the last 14 days? Please check: __________ YES ___________ NO

_____Fever _____Cough _____Colds _____Difficulty in Breathing _____ Diarrhea _____Sore Throat

Declaration: I hereby certify that the above information is true and complete. I understand that my failure to answer, or any false information or misleading information given by me
may be used as a ground for the filing of case(s) against me under Article 171 and 172 of the Revised Penal Code of the Philippines, or Republic Act No. 11332, otherwise known as
the “Mandatory Reporting of Notifiable Diseases and Health Events of Public Concern Act.”

_______________________________________
Signature over Printed Name