Tanauan City Integrated High School Trapiche 1, Tanauan City, Batangas Health Declaration Form

TANAUAN CITY INTEGRATED HIGH SCHOOL
Trapiche 1, Tanauan City, Batangas
Date:
HEALTH DECLARATION FORM
Temperature:
NAME: AGE: SEX: ________

ADDRESS:
CONTACT NO.
Nature of Visit: (Pls. check appropriate box)
Official Company Name:

Conpany Address:
Personal Office/Place of Visit:
Purpose of Visit:
Yes No
1. Are you experiencing a. sore throat (pananakit ng lalamunan)
(nakaraaranas ka ba ng) b. body pains (pananakit ng katawan)
c. headache (pananakit ng ulo)
d. fever for the past few days (lagnat sa nakalipas na mga araw)
e. colds (sipon)
f. cough (ubo)
2. Have you worked together or stayed in the close environment of a confirm COVID-19
case? (May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19 o may
impeksyon ng corona virus?)
3. Have had any contact with anyone with fever, cough, colds and sore throat in the past 2
weeks? (Mayroon ka bang nakasamang may lagnat, ubo, sipon, o sakit sa lalamuna sa
nakalipas na 14 na araw?)
4. Have you ever travelled outside of the Philippines in the last 14 days? (Ikaw ba ay
nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
5. Have you travelled to any area reporting local transmission of COVID-19? (Ikaw ba ay
nagpunta sa iba pang lugar na may kumpirmadong kaso ng COVID-19?)
I hereby authorize Tanauan City Integrated High School to collect and process the data indicated
herein for the purpose of effecting control of the COVOD-19 infrction. I understand that my personal
information is protected by RA 10173 Data Privacy Act of 2012 and I am required by RA 11469
Bayanihan to Heal as Ine Act to provide truthful information.
Signature over printed name

Date:
Temperature:

ADDRESS:
CONTACT NO.

Conpany Address:
Purpose of Visit:
Yes No
e. colds (sipon)
f. cough (ubo)

Date:
Temperature:

ADDRESS:
CONTACT NO.

Conpany Address:
Purpose of Visit:
Yes No
e. colds (sipon)
f. cough (ubo)

Date:
Temperature:

ADDRESS:
CONTACT NO.

Conpany Address:
Purpose of Visit:
Yes No
e. colds (sipon)
f. cough (ubo)

Tanauan City Integrated High School Trapiche 1, Tanauan City, Batangas Health Declaration Form

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Tanauan City Integrated High School Trapiche 1, Tanauan City, Batangas Health Declaration Form

Uploaded by

Copyright:

Available Formats

TANAUAN CITY INTEGRATED HIGH SCHOOL

Trapiche 1, Tanauan City, Batangas

NAME: AGE: SEX: ________

Nature of Visit: (Pls. check appropriate box)

Official Company Name:

Personal Office/Place of Visit:

Signature over printed name

NAME: AGE: SEX: ________

Nature of Visit: (Pls. check appropriate box)

Official Company Name:

Personal Office/Place of Visit:

Signature over printed name

NAME: AGE: SEX: ________

Nature of Visit: (Pls. check appropriate box)

Official Company Name:

Personal Office/Place of Visit:

Signature over printed name

NAME: AGE: SEX: ________

Nature of Visit: (Pls. check appropriate box)

Official Company Name:

Personal Office/Place of Visit:

Signature over printed name

You might also like