HEALTH DECLARATION FORM

To be accomplished Weekly by STEFTI Learners & Employees and submitted upon entering the school campus HEALTH DECLARATION FORM
To be accomplished Weekly by STEFTI Learners & Employees and submitted upon entering the school campus

Date (MM/DD/YY):
Full Name: Time: Date (MM/DD/YY):
Full Name: Time:
Complete Address:
Complete Address:
Mobile No.: Email Address:
Mobile No.: Email Address:
Put a check mark on the appropriate column of your response.
Yes (Oo) No (Hindi) Put a check mark on the appropriate column of your response.
Yes (Oo) No (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon) a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or c. Body Pains (Pananakit ng katawan)
d. Sore Throat (Pananakit o pamamaga ng 1. Are you experiencing or c. Body Pains (Pananakit ng katawan)
did you have any of the
following in the last 14 lalamunan) did you have any of the d. Sore Throat (Pananakit o pamamaga ng
days? (Ikaw ba ay may e. Fatigue/Tiredness (Pagkapagod) following in the last 14 lalamunan)
nararanasan o nakaranas days? (Ikaw ba ay may e. Fatigue/Tiredness (Pagkapagod)
f. Headache (Pananakit ng ulo)
ng mga sumusunod na nararanasan o nakaranas f. Headache (Pananakit ng ulo)
g. Diarrhea (Pagtatae) ng mga sumusunod na
sintomas sa nakaraang 14 g. Diarrhea (Pagtatae)
na araw?) h. Loss of Taste or Smell (Nawalan ng Panlasa sintomas sa nakaraang 14
or Pang-amoy) na araw?) h. Loss of Taste or Smell (Nawalan ng Panlasa
i. Difficulty of Breathing (Pagkahapo o Hirap sa or Pang-amoy)
paghinga) i. Difficulty of Breathing (Pagkahapo o
2. Have you had face-to-face contact with a probable or confirmed COVID-19 case Hirap sa paghinga)
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 case
nakasalamuha ka ba na maaaring o kumpirmadong pasyente na may COVID-19 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 nakasalamuha ka ba na maaaring o kumpirmadong pasyente na may COVID-19
labinlimang minute sa nakalipas na 14 araw?) mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit
3. Have your provided direct care for a patient with probable or confirmed COVID- labinlimang minute sa nakalipas na 14 araw?)
19 case without using proper “Personal Protective Equipment (PPE)” for the past 14 3. Have your provided direct care for a patient with probable or confirmed COVID-
days? (Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 19 case without using proper “Personal Protective Equipment (PPE)” for the past 14
ng hindi nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na days? (Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19
14 araw?) ng hindi nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na
4. Have you traveled outside the Philippines in the last 14 days? (Ikaw ba ay 14 araw?)
nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?) 4. Have you traveled outside the Philippines in the last 14 days? (Ikaw ba ay
5. Have you traveled outside the current city/municipality where you reside? (Ikaw nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?)
ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify which 5. Have you traveled outside the current city/municipality where you reside? (Ikaw
city/municipality you went to. (Sabihin kung saan): __________ ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify which
city/municipality you went to. (Sabihin kung saan): __________
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any question or any
falsified response may have serious consequences. I understand that my personal information is protected by RA 10173 or the I hereby certify that the information given is true, correct and complete. I understand that failure to answer any question or any
Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the date of accomplishment, following the falsified response may have serious consequences. I understand that my personal information is protected by RA 10173 or the
National Archives of the Philippines protocol. 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 Above Printed Name ______________________________
Signature Above Printed Name