BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM Date: Body Temperature Name Dose ‘Grade ana Secon Ci Fatyaceinatea ‘Age:_Sex:___ Contact Number: Ey uae ithaay. aadress [ae yeu oxpenereng Seve Taal? BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM at Body Temperatur Name: Ly #tdeee Grade and Section: C1 Fatly Vaccinated Age:__ Sex:__ Contact Number: as Binthday. Clem aadress Are you openerenng Sore Tic re you expensing bo pai? re you expensing bo pai? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? [ave you raveled any areain Regan Xl aside fom your toms? [ave you raveled any areain Regan Xl aside fom your toms? ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM ate: Body Temperatu Name: Ly #tdeee Grade and Section: C1 Fatly Vaccinated ‘Contact Number Li emacc ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM ate: Body Temperatur Name: Ly #tdeee Grade and Section: C1 Fatly Vaccinated Age:__ Sex:__ Contact Number: as = C umaccinated aadress [ae yeu oxpenereng Seve Taal? Are you openereng Sa Ti re you expensing bo pai? re you expensing bo pai? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? [ave you raveled any areain Regan Xl aside fom your toms? [ave you raveled any areain Regan Xl aside fom your toms? ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed