Republic of the Philippines

UNIVERSITY OF SOUTHERN MINDANAO

Kabacan, Cotabato
Telephone No. ( 064) - 572-2518
Email: uls@usm.edu.ph
COLLEGE OF EDUCATION
UNIVERSITY LABORATORY SCHOOL
DepEd School ID: 600102
HEALTH DECLARATION FORM

To prevent the spread of COVID -19 in our community and reduce the risk of exposure
to our faculty, staff, students, parents, and visitors, we are conducting a simple screening
questionnaire. Your participation is important to help us take precautionary measures to
protect you and everyone in this school. Thank you for the time.
Name:
Age: Sex:
Home Address: Mobile No.
1. Are you experiencing YES NO
(Nakakaranas ka ba ng) a. Sore Throat ( pananakit
ng lalamunan/masakit
lumunok)
b. Body pains
pananakit ng katawan
c. Headache (pananakit
ng ulo)
d. Fever for the past days
(lagnat sa nakalipas na
mga araw)
2. Have you come in contact or stayed together in the same close
close environment of a confirmed COVID-19 case?
(May nakasama ka ba o nakatrabahong tao na
kumpirmadong may COVID-19?
3. Have you had any contact with anyone with fever,cough,
colds or sore throat in the past 2 weeks?( Mayroon ka bang
nakasama na may lagnat, ubo, sipon o sakit ng lalamunan
sa nakalipas na dalawang linggo?)
4. Have you travelled to an area where there are high
COVID-19 cases in the last 14 days? ( Ikaw ba ay pumunta
o nagbyahe sa lugar na mayroong mataas na kaso ng
COVID-19 sa nakalipas na labing-apat na araw?)
5. Have you travelled to any area aside from your home
location? Ikaw ba ay nagpunta sa ibang lugar bukod sa
inyong bahay?) Specify(Sabihin kung saan):
I hereby certify that the information given is true, correct and complete. I understand that any
falsified reponse may have serious consequences. I understand that my personal information
is protected by RA 10173 of 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
Philippine protocol.

Name and Signature Date

Enclosure to DepEd-DOH Joint Memorandum Circular on the Operational Guidelines on the

Implementation of Face-to-face Learning Modality