HEALTH DECLARATION CHECKLIST

_________________________________________________
(NAME OF SCHOOL)

Please check Employee Examinee Visitor

Name:________________________________________________ Temp: ________oC

Age: _________ Sex: __________ Contact #: _______________________________
Address: ________________________________________________________________
Office/Purpose: ____________________________ Time In: _________________

Please answer truthfully the following: YES NO

1. Are you currently experiencing:
a. Fever
b. Cough and/or Colds
c. Body Pains
d. Sore Throat
e. Fatigue
f. Headache
g. Diarrhea
h. Loss of Taste or smell
i. Difficulty in breathing
2. Have you been in face-to-face contact with
probable or confirmed COVID-19 case without
using PPE for the past 14 days?
3. Have you travelled outside the current
municipality where you reside in the past 14
days? If Yes, please specify ______________________

I hereby authorize the __________________________________________, 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 RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469,
Bayanihan to Heal as Once Act, to provide truthful information.

Signature: _________________________________ Date: _________________________________