HEALTH DECLARATION FORM

To be submitted to the guard on duty 24 to 72 hours before the scheduled pilot

face-to-face classes.

Grade Level & Section 9-prudence Sex: male Age: 14

Students’ Name Singh Akashdeep
Last Name First Name MI

Complete Address 114 d-tuazon cor maria clara yby Bld brangay Lourdes Quezon city
No. Street Barangay City/Municipality

YES NO
1. Are you experiencing
a. Sore throat
b. Body pains
c. Headache
d. Fever for the past few days
2. Did you stay in the same close environment of a confirmed COVID-19
case for the past two weeks?
3. Did you have close contact with anyone with fever, cough, colds, and sore throat in the past two
weeks?
4. Did you travel outside the Philippines in the last 14 days?
5. Did you travel to any area in NCR or outside Metro Manila aside from home in the past two
weeks?
Pls. specify.

6. Do you have comorbidities, immunodeficiency, and other health risks?

If any, pls. specify:

7. Are you fully vaccinated against COVID -19?

Specify dates: 1st dose 11/13/21 2nd dose 12/4/21

1st Booster: 2nd Booster:

I hereby authorize Lourdes School of Quezon City, to collect and process the data indicated herein for the
purpose of affecting 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
One, to provide truthful information.

Akashdeep singh Sarbjeet Kaur

Signature of Student over Printed Name Signature of Parent over Printed Name Date Contact Nos.