HEALTH

DECLARATION FORM
Temperature: ____________
Name: ________________________________________ Sex: ________ Age __________
Address: ________________________________________________________________

Nature of Visit: Official Personal If official, fill-in company details:

Company Name: ________________________________ Contact No.: ________________
Company Address: ______________________________ CPR No. ____________________
1. Are you experiencing Yes No
(nakakaranas ka ba) a. Sore Throat (pananakit ng lalamunan
/masakit lumunok)
b. Body pains (pananakit ng katawan)
c. Headache (pananakit ng ulo)
d. Fever for the past few days (lagnat sa
nakalipas na araw)
2. Have you worked together or stayed in the same close environment of
a confirmed COVID 19 case? (May nakasama ka ba or nakatrabahong
tao na kumpirmadong may COVID-19 / may inpeksyon ng Corona
Virus?)
3. Have you had any contact with anyone with fever, cough, colds, and
sore throat in the past two weeks? (Mayroon ka bang nakasama na
may lagnat, ubo, sipon, o sakit ng lalamunan sa nakalipas na dalawang
(2) linggo?)
4. Have you traveled outside of Bahrain in the last 14 days? (Ikaw ba ay
nagbyahe sa labas ng Bahrain sa nakalipas na 14 na araw?)
5. Have you traveled to any area in Bahrain aside from your home? (Ikaw
ba ay nagpunta sa iba pang parte ng Bahrain bukod sa iyong bahay?)
Specify (sabihin kung saan): __________________________
_____________________________________________________________
6. Have you tested positive for COVID-19? (Ikaw ba ay nagpositibo sa
COVID-19?)
SWORN STATEMENT
I hereby authorize the Philippine Embassy in Manama, Kingdom of Bahrain, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by R.A. 10173, Data Privacy
Act of 2012. I SOLEMNLY SWEAR UNDER THE PENALTY OF LAW that the statements made on
this form are true, and I understand that I will be liable under the criminal laws of the
Philippines for any false declarations herein. I also understand that exposing others to
infection is a crime under Law No. 34 of 2018 regarding public health, the penalty of which
is up to three years imprisonment, and a fine of up to 10,000 Dinars.

Signature: __________________________ Date: ___________________