Sampaloc Elementary School Main HEALTH DECLARATION FORM

HEALTH DECLARATION FORM Full Name ( Buong Pangalan ) Date ( Petsa )

Time ( Oras ):
Full Name ( Buong Pangalan ) Date ( Petsa )
Complete Current Address (Kasalukuyang Tirahan )
Time ( Oras ):
Complete Current Address (Kasalukuyang Tirahan ) Mobile/Phone Number( Numero ng Telepono):
Guro: KATHLYN JOYCE P. MAGNAYE
Mobile/Phone Number( Numero ng Telepono):
Put a check mark on the appropriate column of your response. ( Lagyan ng tsek a angkop na sagot )
Guro: KATHLYN JOYCE P. MAGNAYE
a. fever (lagnat) Yes (Oo) No(Hindi)
Put a check mark on the appropriate column of your response. ( Lagyan ng tsek a angkop na sagot )
1.Are you experiencing or b. coughand /or colds( Uboat /sipon
a. fever (lagnat) Yes (Oo) No(Hindi) did you have any of the c. body pains ( panankit ng kalamnan)
1.Are you experiencing or b. coughand /or colds( Uboat /sipon following in the last 14
days?( Ikaw ba ay may d. Sore Throat( Pannaakit o pamamaga ng
did you have any of the c. body pains ( panankit ng kalamnan)
nararanasan o nakararanas lalamunan
following in the last 14
d. Sore Throat( Pannaakit o pamamaga ng ng mga sumusunod na e. Fatigue/Tiredness( Pagkapagod)
days?( Ikaw ba ay may
nararanasan o nakararanas lalamunan sintomas sa nakaraang 14 f. Headache ( Pananakit ng ulo)
ng mga sumusunod na e. Fatigue/Tiredness( Pagkapagod) na araw?) g. diarrhea (pagtatae)
sintomas sa nakaraang 14 f. Headache ( Pananakit ng ulo)
na araw?) h. difficulty of breathing( Pagkakahapo o hirap sa
g. diarrhea (pagtatae) paghinga)
h. difficulty of breathing( Pagkakahapo o hirap sa 2. Have you had face –to-face contact with a probable or confirmed COVID-19
paghinga) case within 1 meter and for more than 15 minutes for the past 14 days? ( May
2. Have you had face –to-face contact with a probable or confirmed COVID-19 nakasalamuha ka ba na maaari o kumpirmadong pasyente na may COVID-19
case within 1 meter and for more than 15 minutes for the past 14 days? ( May mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit 15
nakasalamuha ka ba na maaari o kumpirmadong pasyente na may COVID-19 minuto sa nakalipas na 14 araw?
mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit 15 3. Have you provided direct care for a patient with probable or confirmed
minuto sa nakalipas na 14 araw? COVID-19 case without using proper “Personal Protective Equipment(PPE)” for
3. Have you provided direct care for a patient with probable or confirmed the past 14 days?( Nag-alaga ka ba ng maaari o kumpirmadong pasyente na
COVID-19 case without using proper “Personal Protective Equipment(PPE)” for may COVID-19 ng hindi nakasuot ng tamang PPE ( Personal Protective
the past 14 days?( Nag-alaga ka ba ng maaari o kumpirmadong pasyente na Equipment sa nakalipas na 14 na araw?)
may COVID-19 ng hindi nakasuot ng tamang PPE ( Personal Protective 4. Have you traveled outside the Philippines in the last 14 days? ( Ikaw ba
Equipment sa nakalipas na 14 na araw?) nagbiyahe sa labas ng Pilipinas san a nakalipas na 14 na araw?)
4. Have you traveled outside the Philippines in the last 14 days? ( Ikaw ba 5.Have you traveled outside the current city/ municipality where you reside?
nagbiyahe sa labas ng Pilipinas san a nakalipas na 14 na araw?) ( Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/ munisipyo?) If yes,specifywhich
5.Have you traveled outside the current city/ municipality where you reside? city/municipality you went to ( Sabihin kung saan)__________
( Ikaw ba ay nagbiyahe sa labas ng iyong lungsod/ munisipyo?) If yes,specifywhich I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
city/municipality you went to ( Sabihin kung saan)__________ question or any falsified response may have serious consequences.I understand that my personal information is
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any protected by RA10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from
question or any falsified response may have serious consequences.I understand that my personal information is the date of accomplishment, following the National Archives of the Philippines protocol.
protected by RA10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from
the date of accomplishment, following the National Archives of the Philippines protocol. Signature: (Lagda):_____________________________

Signature: (Lagda):_____________________________

Sampaloc Elementary School Main