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Health Declaration Form for Travel

This health declaration form from Sta. Cruz National High School collects health information from students, including any symptoms of fever, cough, cold, sore throat, preexisting conditions like diabetes or hypertension, and travel history. The form is used to determine if the student is suspected, probable, or confirmed to have COVID-19 and whether they are allowed to travel. It must be signed by a health worker and local official to verify the student's health status.

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Rodney Saja
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66 views1 page

Health Declaration Form for Travel

This health declaration form from Sta. Cruz National High School collects health information from students, including any symptoms of fever, cough, cold, sore throat, preexisting conditions like diabetes or hypertension, and travel history. The form is used to determine if the student is suspected, probable, or confirmed to have COVID-19 and whether they are allowed to travel. It must be signed by a health worker and local official to verify the student's health status.

Uploaded by

Rodney Saja
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Department of Education

Region VIII – Eastern Visayas


Division of Southern Leyte
District of Malitbog
STA. CRUZ NATIONAL HIGH SCHOOL
School ID: 303488
HEALTH DECLARATION FORM
Address:
Please check if you have following conditions(s):
________ Diabetes ________ Hypertension _________ Asthma _________ Kidney Disease Date:_______________________

BODY TEMP.
ANY SYMPTOMS OF THE FOLLOWING With Travel CHECKED
History with Signature of
Local BHW/BHERT
Name of Student FEVER COUGH COLD SORE Transmission
(YES / NO) (YES / NO) (YES / NO) THROAT Member on
(YES / NO) Duty
Indicate Body (YES / NO)
Temperature

This form indicate that the above-mentioned person is NOT A COVID-19 SUSPECT, PROBABLE, OR CONFIRMED CASE and is
ALLOWED TO TRAVEL.

Checked by: Certified by: Name of


Driver:
__________________________

___________________________ _____________________________ Plate


Health Worker / BHERT PUNONG BARANGAY Number:
___________________________
Contact No. (If known)
___________________________
---------------------------------------------------------------------------------------------------------------------------------------------
Department of Education
Region VIII – Eastern Visayas
Division of Southern Leyte
District of Malitbog
STA. CRUZ NATIONAL HIGH SCHOOL
School ID: 303488
HEALTH DECLARATION FORM
Address:
Please check if you have following conditions(s):
________ Diabetes ________ Hypertension _________ Asthma _________ Kidney Disease Date:_______________________

BODY TEMP.
ANY SYMPTOMS OF THE FOLLOWING With Travel CHECKED
History with Signature of
Local BHW/BHERT
Name of Student FEVER COUGH COLD SORE Transmission
(YES / NO) (YES / NO) (YES / NO) THROAT Member on
(YES / NO) Duty
Indicate Body (YES / NO)
Temperature

This form indicate that the above-mentioned person is NOT A COVID-19 SUSPECT, PROBABLE, OR CONFIRMED CASE and is
ALLOWED TO TRAVEL.

Checked by: Certified by: Name of


Driver:
__________________________

___________________________ _____________________________ Plate


Health Worker / BHERT PUNONG BARANGAY Number:
___________________________
Contact No. (If known)
___________________________

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