HEALTH DECLARATION FORM

HEALTH DECLARATION FORM

Date:____________________ Temperature: ___________
Date:__________ ______ Temperature: _______________
Name:____________________________________________
Name:____________________________________________
Sex:____ Age: ____ Contact #: _______________________
Sex:________ Age: ____ Contact #: ___________________
Grade level: __________________________ Group:________
Grade level: __________________________ Group:________
1. Are you Yes No
experiencing 1. Are you Yes No
(nakakaranas experiencing
a. Sore throat
kaba) (nakakaranas
(pananakit ng e. Sore throat
kaba)
lalamunan/masaki (pananakit ng
t lumunok lalamunan/masaki
b. Body pains t lumunok
(pananakit ng f. Body pains
katawan) (pananakit ng
c. Headcahe(panana katawan)
kit ng ulo) g. Headcahe(panana
d. Fever for the past kit ng ulo)
few days(lagnat sa h. Fever for the past
nakalipas na araw) few days(lagnat sa
2. Have you worked together or stayed in the nakalipas na araw)
same close environment of a confirmed 2. Have you worked together or stayed in the
COVID 19 case? (May nakasama ka ba or same close environment of a confirmed
nakatrabahong tao na kumpirmadong may COVID 19 case? (May nakasama ka ba or
COVID-19/ may inpeksyon ng Corona Virus?) nakatrabahong tao na kumpirmadong may
3. Have you had any contact with anyone with COVID-19/ may inpeksyon ng Corona Virus?)
fever, cough, colds, and sore throat in the 3. Have you had any contact with anyone with
past two weeks? fever, cough, colds, and sore throat in the
Mayroon ka bang nakasama na may lagnat, past two weeks?
ubo, sipon, o sakit ng lalamunan sa nkalipas Mayroon ka bang nakasama na may lagnat,
na dalawang (2) lingo?) ubo, sipon, o sakit ng lalamunan sa nkalipas
4. Have you travelled outside the municipality in na dalawang (2) lingo?)
the last 14 days? (ikaw ba ay nagbiyahe sa 4. Have you travelled outside the municipality in
nakalipas na 14 araw? the last 14 days? (ikaw ba ay nagbiyahe sa
5. Have you travelled to any area aside from nakalipas na 14 araw?
your home? (ikaw ba ay nagpunta sa iba pang 5. Have you travelled to any area aside from
lugar maliban sa iyong bahay?) Specify your home? (ikaw ba ay nagpunta sa iba pang
(sabihin kung saan): __________________ lugar maliban sa iyong bahay?) Specify
(sabihin kung saan): __________________

SWORN STATEMENT
I hereby authorize the Colegio De Sta. Rita Foundation, Inc. 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.
SWORN STATEMENT
I hereby authorize the Colegio De Sta. Rita Foundation, Inc. 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.

______________________________________________________
SIGNATURE ______________________________________________________
SIGNATURE