Tamag, Vigan City 2700 Ilocos Sur MEDICAL SERVICES OFFICE HEALTH DECLARATION FORM COLLEGE/DEPT/UNIT:_________________ Name: ____________________________________ Are you fully vaccinated? __YES __NO Complete Address: _______________________________________________________ Mobile/Phone Number: _________________ The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 its capacity to transmit disease from person to person through respiratory droplets, our government has set recommendations, guidelines, and some prohibitions which the University of Northern Philippines adheres to DATE:________ DATE:________ DATE:________ DATE:________ DATE:________ DATE:________ comply. In consideration of my participation in the program, the undersigned acknowledges and agrees with the following details by putting a checkmark on the appropriate column of your response. YES NO YES NO YES NO YES NO YES NO YES NO 1. Are you currently experiencing any of the following signs and symptoms? Sore throat Runny nose Cough Headache Fever (temperature above 37.5 ' C) Other symptoms: diarrhea, loss of taste, loss of smell 2. Did you recently come in close contact or are you staying in the same close environment with someone who is a confirmed COVID-19 case? I agree that the information provided in this document is true and correct to the Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C best of my knowledge and I understand that any dishonest answers may have Temperature: ____®C serious legal and public health implications under Republic Act No. 11332 (Mandatory Reporting of Notifiable Diseases and Health Events of Public Health ______________ ______________ ______________ ______________ ______________ ______________ Concern Act). ____ ____ ____ ____ ____ ____ SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE * This form will remain effective until laws and mandates relevant to COVID-19 are lifted. *This form is also subject to revision based on updates provided by the COVID-19 Interagency Task Force and the Department of Health.
Quirino Blvd., Brgy. Tamag, Vigan City, 2700 Ilocos Sur