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Padecio, Louise Andrey C.
Padecio, Louise Andrey C.
AGE 17 y/o GENDER M CONTACT NOS. 09198361729 YEAR/SECTION STEM 12-Y1-12 COLLEGE/STRAND. STEM
Answer each question by placing a check (✓) mark. YES NO
1.Have you been fully vaccinated for COVID-19 during the last 2 weeks? (2 doses, except for Janssen
vaccine which requires only 1 dose)
2.Have you experienced any of the following in the past 14 days
Sore throat
Body pain
Headache
Fever
Cough
Colds
Difficulty of breathing
Diarrhea
- Nausea/vomiting
Tiredness
Loss of taste and/or smell
Skin rash
Red eyes
Loss of movement and/or speech
Chest pain or pressure
3. Have you worked together or stayed in the same close environment with a confirmed COVID-19 case
or PUI who is under self-quarantine in your house or in your neighborhood?
4. Did you have any contact with anyone with fever, cough, colds, and sore throat in the past 14 days?
For students in vulnerable group (VG): I fully understand that I must follow the prevailing guidelines prescribed by the COVID-
19
Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).
I attest that all the information given above are true and correct and that I may be held liable for any misinformation stated
herein. I also authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose of effecting
the control of COVID-19 infection and that my personal information are protected by RA.10173 (Data Privacy Act of 201°C 2)
and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.