NOTRE DAME SIENA COLLEGE OF POLOMOLOK NOTRE DAME SIENA COLLEGE OF POLOMOLOK

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

PERSONAL INFORMATION PERSONAL INFORMATION
(kindly check (/) below if you’re the Guest or the Graduate (kindly check (/) below if you’re the Guest or the Graduate

(__) Im the Guest (__) Im the Graduate (__) Im the Guest (__) Im the Graduate

NAME: Section: NAME: Section:

Contact No: Adviser Name: Contact No: Adviser Name:
Address: Seat Number Graduate: Address: Seat Number Graduate:

Note: Guest are required to fill up the Section, Adviser’s Note: Guest are required to fill up the Section, Adviser’s
Name, Seat Number of Graduate for faster transaction Name, Seat Number of Graduate for faster transaction
YE NO YE NO
S S
Have you been in close contact with a Have you been in close contact with a
confirmed case/s of COVID-19? confirmed case/s of COVID-19?
Have you been in close contact with persons in Have you been in close contact with persons in
quarantine/probable case of COVID-19 quarantine/probable case of COVID-19
Do you have the following signs and symptoms within Do you have the following signs and symptoms within
the last 14 days? the last 14 days?
Fever Fever
Cough Cough
Runny Nose Runny Nose
Sore Throat Sore Throat
Shortness of breath Shortness of breath
Have you undergone COVID-19 detection Have you undergone COVID-19 detection
testing? testing?
Are you fully vaccinated? If yes, kindly attach Are you fully vaccinated? If yes, kindly attach
the photo copy. the photo copy.

________________________ ________________________
Signature Overprinted Name Signature Overprinted Name