West Visayas State University

Health Declaration Form

Name: Farah Maxyne J. Alayon

Department/Office: College of Business and Management, West Visayas State University
Home Address: Brgy. Tabugon, Kabankalan City, Negros Occidental
Contact No.: 09934797750 Email Address: farahmaxyne.alayon@wvsu.edu.ph

DECLARATION: Circle Answer

I was a confirmed case of COVID-19 (Coronavirus). YES __
NO
In the last 14 days, I was in close contact with a confirmed case of COVID-19 YES __
NO
(Coronavirus).
In the last 14 days, I have returned from travel overseas or domestically from a YES __
NO
place with confirmed COVID-19 cases.
In the last 14 days, I was in close contact with someone who has returned from YES __
NO
ANY travel overseas in the last 14 days.
In the last 14 days, I have had close contact with someone with flu-like symptoms YES __
NO
(i.e. fever, cough, sore throat, runny nose, fatigue, difficulty breathing).
I am currently suffering from flu-like symptoms (or in the last 48 hours), which
may include: (check symptom/s)
 Fever (Temp. > than YES __
NO
 Cough/Colds YES __
NO
 Sore-throat YES __
NO
 Running nose or Stuffy nose YES __
NO
 Headache, Aches and Body Pains YES __
NO
 Fatigue YES __
NO
 Breathing Difficulty YES __
NO
 other symptoms (i.e. gastroenteritis related or similar) YES __
NO
*DOH Memo. No. 2020-220
I therefore declare that all the information given in this form is true and correct.

FARAH MAXYNE J. ALAYON

_________________________________ _________________
11-06-22 / 10:00 PM
Employee/Visitor’s Name and Signature Date/Time