HEALTH DECLARATION AND CLEARANCE FORM

Name: Contact no.: Date:

Surname First Name M.I
School/ Dept.: Address: Age: Sex:

Please check (√) if you have any of the following exposure, symptoms or co-morbidities.

I. Exposure Checklist :
YES NO

Travel History within the last 14 days (Travelled from other countries/provinces. Country/province:) _________________________________________
Have CLOSE CONTACT with confirmed COVID-19 positive case within the last 14 days: (Any of the following) nakasalamuha ang isang merong COVID-19
Providing direct care to COVID-19 patient (nag-aalaga sa may COVID-19 sa bahay, ospital o ibang facility)
Staying in the same close environment (merong kasama sa bahay, trabaho, pagtitipon atbp na merong COVID-19 )
Traveling together in close proximity (less than 1 meter or 3 feet) in any kind of vehicle (kalapit sa biyahe)
If Yes, pls, indicate date of exposure:

II. Presence of symptoms within the last 14 days: III. Co-morbidities/Vulnerability: (Meron ka ba nito?)

YES NO YES NO YES NO

Fever (Lagnat) Diarrhea (Pagtatae) Asthma (Hika )

Cough (Ubo) Discolorations of fingers or toes Diabetes (Mataas sugar )
Colds (Sipon) (Pagkawala ng kulay sa daliri at paa) Heart disease (May sakit sa puso )
Sore throat (Masakit lalamunan ) Others (please specify) Hypertension (Mataas blood pressure)
Loss of taste (Pagkawala ng lasa) Obesity (Sobrang taba )
Loss of smell (Pagkawala ng amoy) Any of these symptoms among Pregnancy
housemates or any housemates
Body pains (Masakit ang k at aw a n ) tested positive or a suspected 60 years and above
Conjunctivitis (Pamumula ng mata) COVID-19 case? Others (please specify)
Rashes (Pantal)
Headache (Pagsakit ng ulo)

IV. Was a COVID-19 positive case within the last 14 days?

YES NO

If Yes, please indicate the date of RT-PCR or antigen test:

Upon signing this form, you are giving your consent to CEU to process your personal and sensitive personal information. All information will be used to protect public health and safety during
this pandemic. Rest assured that all information will be kept confidential.
I promise to inform my consultant of any symptoms, travel or significant exposure from the time of issuance of clearance to submission of this form, aware of possible disciplinary action of my
failure to do so.
I attest to the truth of all my above answers to this checklist.
BY SIGNING THIS FORM, I ALSO SIGNIFY THAT I HAVE READ, UNDERSTOOD AND WILL COMPLY WITH UNIVERSITY HEALTH PROTOCOLS AGAINST COVID-19.

Noted by:

Time. In: Temp. In: Signature

Security Personnel
Revision 4: 4/10/2021