Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

DIVISION OF AGUSANDEL NORTE DIVISION OF AGUSAN DEL NORTE
BUENAVISTA SPECIAL EDUCATION HIGH SCHOOL BUENAVISTA SPECIAL EDUCATION HIGHSCHOOL

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Dear students, Dear students,

To prevent the spread of COVID 19 in our community and reduce the risk of
exposure, we would like to request your cooperation by kindly accomplishing
the health survey form below. Your participation is important to help in
instituting precautionary measures in the workplace. Any information that
you have provided will be handled according to the Privacy Act and will only
be used if contact tracing is necessary. Thank you for your time.
NAME: DATE:
Grade & Section: Temperature:
To prevent the spread of COVID 19 in our community and reduce the risk of exposure,
we would like to request your cooperation by kindly accomplishing the health survey
form below. Your cooperation is important to help in instituting precautionary
measures in the workplace. Any information that you have provided will ne handled
according to the Privacy Act and will only be used if contact tracing is necessary. Thank
you for your time.

1. In the past 14 days, which of the following symptom(s) have you experienced, please check ( )
the relevant box(es)

Fever Dry cough Sore throat Tiredness

Diarrhea Shortness of breath Body aches Runny nose

Headache NONE OF THE ABOVE

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

Yes No
3. Have you been identified to high risk areas of COVtD-19 in the past 14 days?

Yes No If yes, please indicate the area(S):

Declaration and Data Privacy Consent Form:
The information I have given is true, correct and complete, I understand that failure to answer any
question or giving false answer can be penalized in accordance with law.
I voluntarily and freely consent to the collection and sharing of the above personal information only
in relation to the DepEd AGUSAN DEL NORTE COVID-19 internal protocols.
_______________________ _____________________
Signature Date

Please be advised that the above information shall only be used in relation to DepEd COVID-19
internal protocols in accordance with the Data Privacy Act.
NAME: DATE:
Grade & Section: Temperature:
1. In the past 14 days, which of the following symptom(s) have you experienced, please check (

) the relevant box(es)

Fever Dry cough Sore throat Tiredness

Diarrhea Shortness of breath Body aches Runny nose

Headache NONE OF THE ABOVE

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

Yes No
3. Have you been identified to high risk areas of COVtD-19 in the past 14 days?

Yes No If yes, please indicate the area(S):

Declaration and Data Privacy Consent Form:
The information I have given is true, correct and complete, I understand that failure to answer
any question or giving false answer can be penalized in accordance with law.
I voluntarily and freely consent to the collection and sharing of the above personal information
only in relation to the DepEd AGUSAN DEL NORTE COVID-19 internal protocols.
_______________________ _____________________
Signature Date

Please be advised that the above information shall only be used in relation to DepEd COVID-19
internal protocols in accordance with the Data Privacy Act.
 Republic of the Philippines Republic of the Philippines
Department of Education Department of Education
DIVISION OF AGUSANDEL NORTE DIVISION OF AGUSAN DEL NORTE
BUENAVISTA SPECIAL EDUCATION HIGH SCHOOL BUENAVISTA SPECIAL EDUCATION HIGHSCHOOL

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Dear students, Dear students,

To prevent the spread of COVID 19 in our community and reduce the risk of
exposure, we would like to request your cooperation by kindly accomplishing
the health survey form below. Your participation is important to help in
instituting precautionary measures in the workplace. Any information that
you have provided will be handled according to the Privacy Act and will only
be used if contact tracing is necessary. Thank you for your time.
NAME: DATE:
Grade & Section: Temperature:
To prevent the spread of COVID 19 in our community and reduce the risk of exposure,
we would like to request your cooperation by kindly accomplishing the health survey
form below. Your cooperation is important to help in instituting precautionary
measures in the workplace. Any information that you have provided will ne handled
according to the Privacy Act and will only be used if contact tracing is necessary. Thank
you for your time.

1. In the past 14 days, which of the following symptom(s) have you experienced, please check ( )
the relevant box(es)

Fever Dry cough Sore throat Tiredness

Diarrhea Shortness of breath Body aches Runny nose

Headache NONE OF THE ABOVE

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

Yes No
3. Have you been identified to high risk areas of COVtD-19 in the past 14 days?

Yes No If yes, please indicate the area(S):

Declaration and Data Privacy Consent Form:
The information I have given is true, correct and complete, I understand that failure to answer any
question or giving false answer can be penalized in accordance with law.
I voluntarily and freely consent to the collection and sharing of the above personal information only
in relation to the DepEd AGUSAN DEL NORTE COVID-19 internal protocols.
_______________________ _____________________
Signature Date

Please be advised that the above information shall only be used in relation to DepEd COVID-19
internal protocols in accordance with the Data Privacy Act.
NAME: DATE:
Grade & Section: Temperature:
1. In the past 14 days, which of the following symptom(s) have you experienced, please check (

) the relevant box(es)

Fever Dry cough Sore throat Tiredness

Diarrhea Shortness of breath Body aches Runny nose

Headache NONE OF THE ABOVE

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

Yes No
3. Have you been identified to high risk areas of COVtD-19 in the past 14 days?

Yes No If yes, please indicate the area(S):

Declaration and Data Privacy Consent Form:
The information I have given is true, correct and complete, I understand that failure to answer
any question or giving false answer can be penalized in accordance with law.
I voluntarily and freely consent to the collection and sharing of the above personal information
only in relation to the DepEd AGUSAN DEL NORTE COVID-19 internal protocols.
_______________________ _____________________
Signature Date

Please be advised that the above information shall only be used in relation to DepEd COVID-19
internal protocols in accordance with the Data Privacy Act.