HEALTH DECLARATION FORM

(to be submitted physically upon entry to the campus)

Name: __________________________________________________________ Temperature: ________

Address: _________________________________________________________________________________
Contact Number: ___________________________________________________________________________

Mode of Transportation used going to Trace College today (check ALL that applies):
[ ] Jeepney [ ] Bus [ ] Private Car
[ ] Tricycle [ ] Pedicab [ ] Trolley
[ ] Bicycle / Private Motorcycle

Place(s) visited BEFORE going to Trace College today (kindly list down all):
1. 4.
2. 5.
3. 6.

*Please tick an answer for every question:

YES NO
Have you been recently tested for Covid-19?
Swab [ ] Rapid test [ ]
Date tested: __________ Result: __________
Have you been evaluated as Probable or Suspected for Covid-19? If YES, when did
your quarantine start?
Have you travelled outside of Laguna within the last 14 days? If YES,

When: _______________ Where: ____________________

Did you come in close contact or staying in the same area with someone who is a
confirmed COVID-19 case?
Did you come in close contact with a Probable or Suspected person with COVID-
19 (anywhere including in your daily commute)?
Have you experienced the following symptoms recently?
a. Fever (37.6 degree Celsius)
b. Diarrhea, Nausea or Vomiting
c. Shortness of breath or other respiratory symptoms?
d. Headache
e. Joint Pain or Muscle Pain
Flu-like symptoms:
f. Chills or repeated shaking with chills
g. Body aches
h. Sore throat
i. Runny nose or Sneezing
j. Cough and Colds
k. Loss of smell and/or taste
l. Eye discharge
m. Skin rash or discoloration of toes/fingers

In compliance with R.A No. 11332 “Mandatory Reporting of Notifiable Diseases and Health Events of Public
Health Concern Act” and R.A No. 11469 “Bayanihan to Heal as One Act”, the School is required to gather the
following information. Everyone is required to comply and provide truthful information or Reporting of one’s
health condition and possible exposure. Failure / refusal to provide truthful information hereunder are required
under relevant issuance is penalized under Section 9 of RA No. 11332.

_______________________________ _______________________
Student Signature over Printed Name Date
(to be signed by parent for Kinder to Grade 6 students)