Republic of the Philippines

Department of Education Department of Education Department of Education

REGION VI – WESTERN VISAYAS REGION VI – WESTERN VISAYAS REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
SAN LUIS ELEMENTARY SCHOOL SAN LUIS ELEMENTARY SCHOOL SAN LUIS ELEMENTARY SCHOOL
SARA, ILOILO SARA, ILOILO SARA, ILOILO

Safety Protocols Amidst COVID 19 Pandemic Safety Protocols Amidst COVID 19 Pandemic Safety Protocols Amidst COVID 19 Pandemic
HEALTH DECLARATION FORM HEALTH DECLARATION FORM HEALTH DECLARATION FORM
Note : School Personnel/Parents/Visitors/Learners are required to Note : School Personnel/Parents/Visitors/Learners are required to Note : School Personnel/Parents/Visitors/Learners are required to
accomplish the health questionnaire prior to enter SLES. accomplish the health questionnaire prior to enter SLES. accomplish the health questionnaire prior to enter SLES.
Please complete and submit. Please complete and submit. Please complete and submit.
Full Name: Full Name: Full Name:
Last Name First Name Middle Name Last Name First Name Middle Name Last Name First Name Middle Name
Address: Sex: Age Temperature: Address: Sex: Age Temperature: Address: Sex: Age Temperature:
: : :
a.Loss of Taste (Indi ka Panabor) Yes No a.Loss of Taste (Indi ka Panabor) Yes No a.Loss of Taste (Indi ka Panabor) Yes No
b.Loss of Smell (Indi ka Panimaho) Yes No b.Loss of Smell (Indi ka Panimaho) Yes No b.Loss of Smell (Indi ka Panimaho) Yes No
c.Diarhhea (Lupot) Yes No c.Diarhhea (Lupot) Yes No c.Diarhhea (Lupot) Yes No
Are you d.Cough (Ubo) Yes No Are you Are you
d.Cough (Ubo) Yes No d.Cough (Ubo) Yes No
Experiencing: Experiencing: Experiencing:
e.Sore Throat Yes No e.Sore Throat Yes No e.Sore Throat Yes No
(Palanakit sang Tutunlan) (Palanakit sang Tutunlan) (Palanakit sang Tutunlan)
(Ikaw bala f.Body Pain Yes No (Ikaw bala f.Body Pain Yes No (Ikaw bala f.Body Pain Yes No
kaagi (Palanakit sang kalawasan) kaagi (Palanakit sang kalawasan) kaagi (Palanakit sang kalawasan)
eksperyensya: g.Headache Yes No eksperyensya: eksperyensya:
g.Headache Yes No g.Headache Yes No
(Palanakit sang ulo) (Palanakit sang ulo) (Palanakit sang ulo)
h.Fever for the past few days Yes No h.Fever for the past few days Yes No h.Fever for the past few days Yes No
(Hilanat sang nagligad nga inadlaw) (Hilanat sang nagligad nga inadlaw) (Hilanat sang nagligad nga inadlaw)
2.Have you worked together or stayed in the same Yes No 2.Have you worked together or stayed in the same Yes No 2.Have you worked together or stayed in the same Yes No
Close environment of a confirmed COVID 19-case? Close environment of a confirmed COVID 19-case? Close environment of a confirmed COVID 19-case?
(Kaagi ka bala upod ukon may naupod sa obra nga (Kaagi ka bala upod ukon may naupod sa obra nga (Kaagi ka bala upod ukon may naupod sa obra nga
kumpirmado nga may COVID-19 nga kaso) kumpirmado nga may COVID-19 nga kaso) kumpirmado nga may COVID-19 nga kaso)
3.Have you had contact with anyone with fever,cough, Yes No 3.Have you had contact with anyone with fever,cough, Yes No 3.Have you had contact with anyone with fever,cough, Yes No
Colds,and sore throats for the past 14 days? Colds,and sore throats for the past 14 days? Colds,and sore throats for the past 14 days?
(Kaagi ka bala nakaupod sa may mga trangkaso,ubo,hilanat (Kaagi ka bala nakaupod sa may mga trangkaso,ubo,hilanat (Kaagi ka bala nakaupod sa may mga trangkaso,ubo,hilanat
o sakit sa sang tutunlan sa nagligad nga duha ka semana? o sakit sa sang tutunlan sa nagligad nga duha ka semana? o sakit sa sang tutunlan sa nagligad nga duha ka semana?
4. Have you travelled outside of the Phillipines in the last Yes No 4. Have you travelled outside of the Phillipines in the last Yes No 4. Have you travelled outside of the Phillipines in the last Yes No
14 days? 14 days? 14 days?
(Kaagi ka bala byahe sa gwa sang Pilipinas sang nagligad (Kaagi ka bala byahe sa gwa sang Pilipinas sang nagligad (Kaagi ka bala byahe sa gwa sang Pilipinas sang nagligad
nga duha ka semana? nga duha ka semana? nga duha ka semana?

Certification and Data Privacy Consent Certification and Data Privacy Consent Certification and Data Privacy Consent
I hereby certify that the information I provided is true, correct and complete. I hereby I hereby certify that the information I provided is true, correct and complete. I hereby I hereby certify that the information I provided is true, correct and complete. I hereby
authorize this school to collect and process the information indicated herein, in authorize this school to collect and process the information indicated herein, in authorize this school to collect and process the information indicated herein, in
accordance with the DOH Health Standards for control of the COVID-19 infections. accordance with the DOH Health Standards for control of the COVID-19 infections. accordance with the DOH Health Standards for control of the COVID-19 infections.

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Signature Over Printed Name Contact Number Date Signature Over Printed Name Contact Number Date Signature Over Printed Name Contact Number Date