Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD

Tourists
Verification ID: 7B698796-331F-42ED-A2ED-6BD3CC641610; Date/Time: 2022-05-17 02:45:01; User ID: 1
-- Please read before proceeding --
In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you will be providing in this

form shall not be used for other purposes except for

COVID-19 contact-tracing activities

ae283c7f-ecc3-4279-8847-aaee9e3cc169 Arrival Date (yyyy-mm-dd): 2022-05-19

Email: chinolerin14@gmail.com Contact No: 09618138784

Passport No/Valid ID Type & No: D2219007003

Name: First Name

Middle Name
Last Name

RODNYMARK LERIN FERNANDEZ

Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 1993-08-19

Flight/Bus Number/Vessel Name: 5J 2001 Seat No: -

Residence Address
Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): B9 L17 PH 1A LAZONES ST SAN LORENZO SOUTH MALITLIT

Municipality/City
Province
Region

SANTA ROSA LAGUNA IV-A

Country(ies) worked, visited and transited in the last 30 days.

NA

H E A L T H   P R O F I L E
1. Have you been sick (cough, difficulty breathing, colds, sore throat, fever) in the past 30
days?  [  ] Yes   []No

2. Have you been exposed to a confirmed case of COVID-19 ?

days?  [  ] Yes   []No

3. Have you been tested positive for COVID-19 using RT-PCR Test ?
  [  ] Yes   []No

Upon submitting, I am providing consent to sharing my information for contact tracing purposes, I confirm that the information I have
given is true, correct and complete and that
I understand failure to answer any question may have serious consequences under
Philippines laws. (Article 171 and 172 of the Revised Penal Code of the Philippines)

Signature