NORSU HEALTH DECLARATION FORM 1

Please Check Event: ___ Limited Face-to-Face Classes ___ University Transaction/s Others (Pls Specify): _______________________________
NAME: _____________________________________ AGE: ____ SEX: ____ COLLEGE: ________________ DATE: _______________
ADDRESS: ________________________________ CONTACT #: _________________________ COURSE & YR: _______________________
Please Check Status: ___ Student ___ Employee ___ Parent/Guardian ___ Guest ___ Others (Pls Specify): __________________
VACCINATION STATUS (Please check): (___) Fully Vaccinated (With or without Booster) (___) Partially Vaccinated (___) Unvaccinated
NOTE: Unvaccinated & Partially vaccinated persons must sign waiver. Not allowed to enter the campus if with any of the “YES” answer below.
By entering the venue/university campus, I attest to the following (Please Put a Check Mark on the Blank):
1.) Yes ____ No ____ : Do you have cough, colds, loss of sense of taste/smell, fever, sore throat, difficulty of breathing or any other respiratory
symptoms as of the present & in the past 2 days?
2.) Yes ____ No ____ : Are you presently sick (including any contagious disease/s)?
3.) Yes ____ No ____ : Are you providing direct care on a probable/confirmed COVID-19 case without proper personal protective equipment?
4.) Yes ____ No ____ : Do you have direct physical contact, or lived, worked, or transacted in close proximity (less than a meter) for more than
15 minutes with a symptomatic Primary (1st degree) Close Contact, Probable or Confirmed COVID-19 case in the past 5
days(for fully vaccinated)/in the past 14 days(for unvaccinated & partially vaccinated)?
5.) Yes ____ No ____ : Are you diagnosed with COVID-19 in the past 7 days(fully vaccinated)/in the past 10 days(unvaccinated/partially)?
6.) Yes ____ No ____ : Are you awaiting any COVID-19 test result that was done on you for the past 7 days?
Following the above pronouncements, I hereby declare that I am telling the truth for the safety of myself and the people around me inside the
said venue/university campus. I authorize the university to collect & process data above for COVID-19 concerns & contact tracing.

______________________________________________
Signature of Individual
--------------------------------Pls Cut Here------------------------ Pls Cut Here ----------------------------- Pls Cut Here -----------------------------------
NORSU HEALTH DECLARATION FORM 1
Please Check Event: ___ Limited Face-to-Face Classes ___ University Transaction/s Others (Pls Specify): _______________________________
NAME: _____________________________________ AGE: ____ SEX: ____ COLLEGE: ________________ DATE: _______________
ADDRESS: ________________________________ CONTACT #: _________________________ COURSE & YR: _______________________
Please Check Status: ___ Student ___ Employee ___ Parent/Guardian ___ Guest ___ Others (Pls Specify): __________________
VACCINATION STATUS (Please check): (___) Fully Vaccinated (With or without Booster) (___) Partially Vaccinated (___) Unvaccinated
NOTE: Unvaccinated & Partially vaccinated persons must sign waiver. Not allowed to enter the campus if with any of the “YES” answer below.
By entering the venue/university campus, I attest to the following (Please Put a Check Mark on the Blank):
1.) Yes ____ No ____ : Do you have cough, colds, loss of sense of taste/smell, fever, sore throat, difficulty of breathing or any other respiratory
symptoms as of the present & in the past 2 days?
2.) Yes ____ No ____ : Are you presently sick (including any contagious disease/s)?
3.) Yes ____ No ____ : Are you providing direct care on a probable/confirmed COVID-19 case without proper personal protective equipment?
4.) Yes ____ No ____ : Do you have direct physical contact, or lived, worked, or transacted in close proximity (less than a meter) for more than
15 minutes with a symptomatic Primary (1st degree) Close Contact, Probable or Confirmed COVID-19 case in the past 5
days(for fully vaccinated)/in the past 14 days(for unvaccinated & partially vaccinated)?
5.) Yes ____ No ____ : Are you diagnosed with COVID-19 in the past 7 days(fully vaccinated)/in the past 10 days(unvaccinated/partially)?
6.) Yes ____ No ____ : Are you awaiting any COVID-19 test result that was done on you for the past 7 days?
Following the above pronouncements, I hereby declare that I am telling the truth for the safety of myself and the people around me inside the
said venue/university campus. I authorize the university to collect & process data above for COVID-19 concerns & contact tracing.

______________________________________________
Signature of Individual

--------------------------------Pls Cut Here------------------------ Pls Cut Here ----------------------------- Pls Cut Here -----------------------------------

NORSU HEALTH DECLARATION FORM 1

Please Check Event: ___ Limited Face-to-Face Classes ___ University Transaction/s Others (Pls Specify): _______________________________
NAME: _____________________________________ AGE: ____ SEX: ____ COLLEGE: ________________ DATE: _______________
ADDRESS: ________________________________ CONTACT #: _________________________ COURSE & YR: _______________________
Please Check Status: ___ Student ___ Employee ___ Parent/Guardian ___ Guest ___ Others (Pls Specify): __________________
VACCINATION STATUS (Please check): (___) Fully Vaccinated (With or without Booster) (___) Partially Vaccinated (___) Unvaccinated
NOTE: Unvaccinated & Partially vaccinated persons must sign waiver. Not allowed to enter the campus if with any of the “YES” answer below.
By entering the venue/university campus, I attest to the following (Please Put a Check Mark on the Blank):
1.) Yes ____ No ____ : Do you have cough, colds, loss of sense of taste/smell, fever, sore throat, difficulty of breathing or any other respiratory
symptoms as of the present & in the past 2 days?
2.) Yes ____ No ____ : Are you presently sick (including any contagious disease/s)?
3.) Yes ____ No ____ : Are you providing direct care on a probable/confirmed COVID-19 case without proper personal protective equipment?
4.) Yes ____ No ____ : Do you have direct physical contact, or lived, worked, or transacted in close proximity (less than a meter) for more than
15 minutes with a symptomatic Primary (1st degree) Close Contact, Probable or Confirmed COVID-19 case in the past 5
days(for fully vaccinated)/in the past 14 days(for unvaccinated & partially vaccinated)?
5.) Yes ____ No ____ : Are you diagnosed with COVID-19 in the past 7 days(fully vaccinated)/in the past 10 days(unvaccinated/partially)?
6.) Yes ____ No ____ : Are you awaiting any COVID-19 test result that was done on you for the past 7 days?
Following the above pronouncements, I hereby declare that I am telling the truth for the safety of myself and the people around me inside the
said venue/university campus. I authorize the university to collect & process data above for COVID-19 concerns & contact tracing.

______________________________________________
Signature of Individual