HEALTH ASSESSMENT FORM FOR STUDENTS HWC 044-22-00

NAME Jamiel Lyca A. Dile CAMPUS Valenzuela Campus

AGE 20 GENDER Female CONTACT NOS. 09278200545 YEAR/SECTION BSN – 4YA-2 COLLEGE/STRAND. BSN

Answer each question by placing a check (✓) mark. YES NO

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)
2.Have you experienced any of the following in the past 14 days
 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:

 60 years old and above /

 Ongoing pregnancy /
 Hypertension /
 Heart disease /
 Diabetes mellitus /
 Recurrent asthma attacks /
 Chronic lung disease- ongoing PTB treatment /
 COPD /
 Cancer /
 Blood dyscrasias /
 Chronic liver and kidney diseases /
 Currently undergoing dialysis treatment /
 Immunocompromised status /
 Autoimmune disease /
 Other Illnesses /
I fully understand that it is the policy of the Our Lady of Fatima University that no students regardless of status shall be
allowed to report for school on campus if any of the abovementioned conditions are present. A student may o nly report back to
school after fo llowing the 14-day quarant ine protocol and submit a medical clearance/fit to school certificate fro m the School
Physician before reporting on campus.

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 2012) and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.

Student’s Signature Over Printed Name:

JAMIEL LYCA A. DILE Date: 10-23- 2022