SCHOOL OF Effectivity:

D Reference No.: Revision No.: 001

NATURAL SCIENCES June, 2021
DEED OF UNDERTAKING FOR LIMITED FACE-TO-FACE
BMLS PROGRAM
INTERNSHIP IN HOSPITAL FACILITIES

Deed of Undertaking (Informed Consent)

I, GOTOH, AARON TZERGIO C. ______________________________________________, of legal age,

assigned at
(name of student)

_UNIVERSITY OF BAGUIO CLINICAL LABORATORY__________________________________________ do hereby

freely and voluntarily declare that:
(Affiliation center)

1. the University of Baguio-School of Natural Sciences (UB-SNS) has explained to me the nature of the limited
face-to-face internship in hospital facilities;
2. I was offered by the UB-SNS the options to either:
a. undergo a limited face-to-face internship in hospital facilities; or
b. file an official leave of absence (LOA) if my family so advise and/or if may medical or psychological
status so warrant. This is without prejudice to the University’s policy on maximum residence and to my
current academic standing;
3. after consulting with my family and after undergoing medical examination, I have chosen to enroll in the
internship program and to undergo the limited face-to-face internship training in hospital facilities. I fully
understand that:
a. while on duty in a hospital facility, I will be working with other interns and laboratory/hospital
personnel; I may also be in direct contact with patients in the hospital;
b. I will not be allowed to rotate in the emergency room, out-patient department, and COVID wards, nor
handle and process specimens from COVID-19 patients;
c. I am fully aware that COVID-19 is highly contagious and can be spread directly from person-to-person
through droplets, aerosols, and possibly through contaminated surfaces and fomites, thus, the risk of
getting infected in the hospital facility is always present.
4. I will abide by the all the safety protocols set in place in this hospital facility, the IATF issuances, and the
local government guidelines including interzonal and intrazonal travel protocols;
5. I am aware of my responsibilities that:
a. I will only report for duty if I am not experiencing any of the signs and symptoms of COVID-19 (fever,
cough, respiratory distress/shortness of breath, sore throat, headache, muscle aches, gastrointestinal
symptoms, and unusual rashes);
b. while on duty, I will wear my complete duty uniform and complete personal protective equipment
(PPE) required by this hospital facility;
6. I shall be watchful of any COVID-19 symptoms and of any contact/exposure and shall immediately inform
my clinical instructors should there be symptoms and/or exposure;
7. I am fully aware that if I tested positive for COVID-19, the hospital facility or UB may be required to notify
the local health authorities and I may also be required to divulge information necessary for data collection
and contact tracing; and
8. I am aware that any violation of the limited face-to-face internship guideline, hospital facility guidelines,
IATF and LGU issuances, may result to a discontinuance of my internship in this affiliation center.

To this undertaking, I hereunto affix my signature this _______JULY 28, 2022________.

(date)

____________________________
Signature of student
_________________________________
Hospital Facility Authorized Signatory
Conforme:
_______________________________
_____ANA LIZA
UB-SNS Authorized Signatory
CERRER_______________________
Printed name and signature of
Parent or Legal Guardian