Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur

MEDICAL SERVICES OFFICE

HEALTH DECLARATION FORM
COLLEGE/DEPT/UNIT: _________________
Name: ____________________________________ Are you fully vaccinated? __YES __NO
Complete Address: _______________________________________________________
Mobile/Phone Number: _________________
The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6
Due to its capacity to transmit disease from person to person through respiratory droplets, our
government has set recommendations, guidelines, and some prohibitions which the University of DATE:________ DATE:________ DATE:________ DATE:________ DATE:________ DATE:________
Northern Philippines adheres to comply. In consideration of my participation in the program, the
undersigned acknowledges and agrees with the following details by putting a checkmark on the YES NO YES NO YES NO YES NO YES NO YES NO
appropriate column of your response.
1. Are you currently experiencing any of the following signs and symptoms?                        
Sore throat                      
Runny nose                        
Cough                        
Headache                        
Fever (temperature above 37.5 ' C)                        
Other symptoms: diarrhea, loss of taste, loss of smell                        
2. Did you recently come in close contact or are you staying in the same close
environment with someone who is a confirmed COVID-19 case?                        
I agree that the information provided in this document is true and correct to the
best of my knowledge and I understand that any dishonest answers may have Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C

serious legal and public health implications under Republic Act No. 11332
(Mandatory Reporting of Notifiable Diseases and Health Events of Public Health ____________ ____________ ____________ ____________ ____________ ____________
Concern Act). ______ ______ ______ ______ ______ ______
SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE
* This form will remain effective until laws and mandates relevant to COVID-19 are lifted.
*This form is also subject to revision based on updates provided by the COVID-19 Interagency Task Force and
the Department of Health.

Quirino Blvd., Brgy. Tamag, Vigan City, 2700 Ilocos Sur

Website: www.unp.edu.ph
Email: medicalservices@unp.edu.ph
Telephone # 09478934563