Full Name (Buong Pangalan): Temperature (Temperatura:) this form will be destroyed after 20 days from date accomplishment,

estroyed after 20 days from date accomplishment, following the National

Archives of the Philippines protocol.
Date (Petsa) (MM/DD/YY:
Signature (Lagda):__________________________________
Time (Oras):
Complete Current Address (Kasalukuyang tirahan): Full Name (Buong Pangalan): Temperature (Temperatura:)

Date (Petsa) (MM/DD/YY:

Mobile/Phone Number (Numero ng telepono):
Email Address: Time (Oras):
Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.) Complete Current Address (Kasalukuyang tirahan):
Yes No
(Oo) (Hindi)
Mobile/Phone Number (Numero ng telepono):
a. Fever (Lagnat)
Email Address:
1. Are you b. Cough and/or Colds (Ubo at/ Sipon) Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)
experiencing or Yes No
did you have any c. Body pains (Pananakit ng katawan) (Oo) (Hindi)
of the following in d. Sore Throat (Pananakit o pamamaga ng
the last 14 days? s. Fever (Lagnat)
lalamunan)
(Ikaw ba ay 1. Are you
e. Fatigue/ Tiredness (Pagkapagod) t. Cough and/or Colds (Ubo at/ Sipon)
may experiencing or
nararanasan o did you have any u. Body pains (Pananakit ng katawan)
f. Headache (Pananakit ng ulo)
nakaranas ng of the following in
mga v. Sore Throat (Pananakit o pamamaga ng
g. Diarrhea (Pagtatae) the last 14 days? lalamunan)
sumusunod sa (Ikaw ba ay
nakaraang 14 h. Loss of taste or smell (Nawalan ng w. Fatigue/ Tiredness (Pagkapagod)
may
na araw?) panlasa o pang amoy)
nararanasan o
i. Difficulty of breathing (Pagkahapo o hirap x. Headache (Pananakit ng ulo)
nakaranas ng
sa pag hinga)
mga y. Diarrhea (Pagtatae)
2. Have you had face-to-face contact with a probable or confirmed sumusunod sa
COVID-19 case within 1 meter and for more than 15 minutes for the nakaraang 14 z. Loss of taste or smell (Nawalan ng panlasa
past 14 days? (May nakasalamuha k aba na maaaring o na araw?) o pang amoy)
kumpirmadong pasyente na may COVID-19 mula sa isang aa. Difficulty of breathing (Pagkahapo o hirap
metrong distansya or mas malapit pa at tumatagal ng sa pag hinga)
mahigit 15 minuto sa nakalipas na 14 araw?) 2. Have you had face-to-face contact with a probable or confirmed
3. Have you provided direct care for a patient with probable or COVID-19 case within 1 meter and for more than 15 minutes for the
confirmed COVID-19 case without using proper “Personal Protective past 14 days? (May nakasalamuha k aba na maaaring o
Equipment (PPE)” for the past 14 days? (Nag-alaga k aba ng kumpirmadong pasyente na may COVID-19 mula sa isang
maaaring o kumpirmadong pasyente na may COVID-19 ng metrong distansya or mas malapit pa at tumatagal ng mahigit
hindi nakasuot ng tamang PPE (Personal Protective 15 minuto sa nakalipas na 14 araw?)
Equipment) sa nakalipas na 14 araw?) 3. Have you provided direct care for a patient with probable or confirmed
4. Have you have travelled outside the Philippines in the last 14 days? COVID-19 case without using proper “Personal Protective Equipment
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na (PPE)” for the past 14 days? (Nag-alaga k aba ng maaaring o
14 na araw?) kumpirmadong pasyente na may COVID-19 ng hindi nakasuot
5. Have you travelled outside current city/municipality where you ng tamang PPE (Personal Protective Equipment) sa nakalipas
reside? (Ikaw ba ay nagbiyahe sa labas ng iyong na 14 araw?)
lungsod/munisipyo?) If yes, specify which city you went to. 4. Have you have travelled outside the Philippines in the last 14 days?
(Sabihin kung saan) (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na
14 na araw?)
I hereby certify that the information given is true, correct and complete. I understand that failure 5. Have you travelled outside current city/municipality where you reside?
to answer any question or any falsified response may have serious consequences. I understand (Ikaw ba ay nagbiyahe sa labas ng iyong
that may personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that lungsod/munisipyo?) If yes, specify which city you went to.
this form will be destroyed after 20 days from date accomplishment, following the National (Sabihin kung saan)
Archives of the Philippines protocol.
I hereby certify that the information given is true, correct and complete. I understand that failure
Signature (Lagda):__________________________________ to answer any question or any falsified response may have serious consequences. I understand
that may personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that
Full Name (Buong Pangalan): Temperature (Temperatura:) this form will be destroyed after 20 days from date accomplishment, following the National
Archives of the Philippines protocol.
Date (Petsa) (MM/DD/YY:
Signature (Lagda):__________________________________
Time (Oras):
Complete Current Address (Kasalukuyang tirahan): Full Name (Buong Pangalan): Temperature (Temperatura:)

Date (Petsa) (MM/DD/YY:

Mobile/Phone Number (Numero ng telepono):
Email Address: Time (Oras):
Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.) Complete Current Address (Kasalukuyang tirahan):
Yes No
(Oo) (Hindi)
j. Fever (Lagnat) Mobile/Phone Number (Numero ng telepono):
Email Address:
1. Are you k. Cough and/or Colds (Ubo at/ Sipon)
experiencing or Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)
did you have any l. Body pains (Pananakit ng katawan) Yes No
of the following (Oo) (Hindi)
m. Sore Throat (Pananakit o pamamaga ng
in the last 14 bb. Fever (Lagnat)
lalamunan)
days? (Ikaw ba
ay may n. Fatigue/ Tiredness (Pagkapagod) 1. Are you cc. Cough and/or Colds (Ubo at/ Sipon)
nararanasan o experiencing or
nakaranas ng o. Headache (Pananakit ng ulo) did you have any dd. Body pains (Pananakit ng katawan)
mga of the following
p. Diarrhea (Pagtatae) ee. Sore Throat (Pananakit o pamamaga ng
sumusunod sa in the last 14
lalamunan)
nakaraang 14 q. Loss of taste or smell (Nawalan ng panlasa days? (Ikaw ba
na araw?) o pang amoy) ay may ff. Fatigue/ Tiredness (Pagkapagod)
r. Difficulty of breathing (Pagkahapo o hirap nararanasan o
gg. Headache (Pananakit ng ulo)
sa pag hinga) nakaranas ng
2. Have you had face-to-face contact with a probable or confirmed mga hh. Diarrhea (Pagtatae)
COVID-19 case within 1 meter and for more than 15 minutes for the sumusunod sa
past 14 days? (May nakasalamuha k aba na maaaring o nakaraang 14 ii. Loss of taste or smell (Nawalan ng panlasa
kumpirmadong pasyente na may COVID-19 mula sa isang na araw?) o pang amoy)
metrong distansya or mas malapit pa at tumatagal ng mahigit jj. Difficulty of breathing (Pagkahapo o hirap
15 minuto sa nakalipas na 14 araw?) sa pag hinga)
3. Have you provided direct care for a patient with probable or confirmed 2. Have you had face-to-face contact with a probable or confirmed
COVID-19 case without using proper “Personal Protective Equipment COVID-19 case within 1 meter and for more than 15 minutes for the
(PPE)” for the past 14 days? (Nag-alaga k aba ng maaaring o past 14 days? (May nakasalamuha k aba na maaaring o
kumpirmadong pasyente na may COVID-19 ng hindi nakasuot kumpirmadong pasyente na may COVID-19 mula sa isang
ng tamang PPE (Personal Protective Equipment) sa nakalipas metrong distansya or mas malapit pa at tumatagal ng mahigit
na 14 araw?) 15 minuto sa nakalipas na 14 araw?)
4. Have you have travelled outside the Philippines in the last 14 days? 3. Have you provided direct care for a patient with probable or confirmed
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na COVID-19 case without using proper “Personal Protective Equipment
14 na araw?) (PPE)” for the past 14 days? (Nag-alaga k aba ng maaaring o
5. Have you travelled outside current city/municipality where you reside? kumpirmadong pasyente na may COVID-19 ng hindi nakasuot
(Ikaw ba ay nagbiyahe sa labas ng iyong ng tamang PPE (Personal Protective Equipment) sa nakalipas
lungsod/munisipyo?) If yes, specify which city you went to. na 14 araw?)
(Sabihin kung saan) 4. Have you have travelled outside the Philippines in the last 14 days?
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na
I hereby certify that the information given is true, correct and complete. I understand that failure 14 na araw?)
to answer any question or any falsified response may have serious consequences. I understand 5. Have you travelled outside current city/municipality where you reside?
(Ikaw ba ay nagbiyahe sa labas ng iyong
that may personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that
lungsod/munisipyo?) If yes, specify which city you went to.
(Sabihin kung saan)
I hereby certify that the information given is true, correct and complete. I understand that failure
to answer any question or any falsified response may have serious consequences. I understand
that may personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that
this form will be destroyed after 20 days from date accomplishment, following the National
Archives of the Philippines protocol.

Signature (Lagda):__________________________________