Republic of the Philippines

DEPARTMENT OF EDUCATION
Region X-Northern Mindanao
Schools Division of Misamis Oriental
District of Initao
TAWANTAWAN INTEGRATED SCHOOL

VISITOR’S HEALTH DECLARATION FORM

Name: _________________________________ Sex: ________ Age: _________
Address/District: __________________________ Temperature: ______________
Contact Number: __________________________

Yes No
1. Are you experiencing any of the following symptoms:
a. FEVER
b. COUGH
c. COLDS
d. DIARRHEA
e. SORE THROAT
f. SHORTNESS OF BREATH
2. Close contact with COVID-19 case?
3. Have you contact with COVID-19 suspect case?
4. Have you any contact with anyone with fever, cough, colds or sore throat in
the last two weeks?
5. Have you travelled outside of the Philippines in the last 14 days?
Where: _____________________________________________________
Date: ______________________________________________________
6. Have you travelled to any area outside your province?
Where: _____________________________________________________
Date: _______________________________________________________

I hereby authorize DepEd Misamis Oriental to collect and process the data indicated herein
for the purpose of effecting control of the COVID-19 infection. I understand that my personal
information is protected by RA 10173, Data Privacy Act of 2012 that I am required by RA 11469,
Bayanihan to Heal as One Act, to provide truthful information.

Signature: _________________________ Date: _______________________ Time:

____________
Purpose:
_______________________________________________________________________________
_______________________________________________________________________________
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