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Health Assessment Form For Student E
Health Assessment Form For Student E
AGE 18 GENDER F CONTACT NOS. 09109213474 YEAR/SECTION SY- 22-23 YA-13 COLLEGE/STRAND. ABM
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)
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? /
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 201°C 2)
and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.
Date
10-
13-
22