Professional Documents
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AGE 21 GENDER MALE CONTACT NOS. 09636365024 YEAR/SECTION 3RD YR DASH 1 COLLEGE/STRAND.
1.Have you been fully vaccinated for COVID-19 during the last 2 weeks? (2 doses, except for Janssen ✓
vaccine which requires only 1 dose)
Sore throat ✓
Body pain ✓
Headache ✓
Fever ✓
Cough ✓
Colds ✓
Difficulty of breathing ✓
Diarrhea ✓
- Nausea/vomiting ✓
Tiredness ✓
Loss of taste and/or smell ✓
Skin rash ✓
Red eyes ✓
Loss of movement and/or speech ✓
Chest pain or pressure ✓
3. Have you worked together or stayed in the same close environment with a confirmed COVID-19 ✓
case
or PUI who is under self-quarantine in your house or in your neighborhood?
4. Did you have any contact with anyone with fever, cough, colds, and sore throat in the past 14 days? ✓
5. Have you travelled outside of the Philippines in the last 14 days? ✓
6. Do you have any of the following conditions: ✓
For students in vulnerable group (VG): I fully understand that I must follow the prevailing guidelines prescribed by the COVID-
19
Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).
I attest that all the information given above are true and correct and that I may be held liable for any misinformation stated
herein. I also authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose of effecting
the control of COVID-19 infection and that my personal information are protected by RA.10173 (Data Privacy Act of 201°C 2)
and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.
Student’s Signature Over Printed Name:
Date