Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

REGION IV-A CALABARZON REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS SCHOOLS DIVISION OF BATANGAS
BAUAN WEST DISTRICT BAUAN WEST DISTRICT
CENTEX Batangas CENTEX Batangas

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

Name (Pangalan): ______________________
Address (Tirahan): _____________________
Grade Level (Pangkat): __________________
Contact Number: _______________________
Date (Petsa): __________________________
Temperature (Temperatura): ______________
Name (Pangalan): ______________________
Address (Tirahan): _____________________
Grade Level (Pangkat): __________________
Contact Number: _______________________
Date (Petsa): __________________________
Temperature (Temperatura): ______________

Please place a check mark under your response. Please place a check mark under your response.
(Lagyan ng tsek sa angkop na sagot). (Lagyan ng tsek sa angkop na sagot).

YES NO YES NO
1.Are you a. Fever (lagnat) 1.Are you a. Fever (lagnat)
experiencing: b. Cough and/ or experiencing: b. Cough and/ or
(Nakakaranas colds (ubo at/o (Nakakaranas colds (ubo at/o
ka ba ng:) sipon) ka ba ng:) sipon)
c. Difficulty of c. Difficulty of
breathing (Hirap breathing (Hirap
sa paghinga) sa paghinga)
d. Sore Throat d. Sore Throat
(Pananakit ng (Pananakit ng
Lalamunan) Lalamunan)
e. Diarrhea e. Diarrhea
(Pagtatae) (Pagtatae)
f. Fatigue/Tiredness f. Fatigue/Tiredness
(Pagkapagod) (Pagkapagod)
g. Headache g. Headache
(Pannakit ng Ulo) (Pannakit ng Ulo)
h. Loss of Taste or h. Loss of Taste or
Smell (Kawalan Smell (Kawalan
ng pang-amoy at ng pang-amoy at
panlasa) panlasa)
i. Body Pains i. Body Pains
(Pananakit ng (Pananakit ng
Katawan) Katawan)
2. My entire household was considered 2. My entire household was considered
a close contact, suspect, probable or a close contact, suspect, probable or
confirmed COVID-19 case the past 14 confirmed COVID-19 case the past 14
days. (Ang aking kasama sa bahay ay days. (Ang aking kasama sa bahay ay
naikonsidera na “close contact”, naikonsidera na “close contact”, suspek,
suspek, probable o kumpirmado na probable o kumpirmado na positibo sa
positibo sa COVID-19 sa nakalipas na COVID-19 sa nakalipas na 14 na araw.)
14 na araw.)
 I hereby certify that the information given is true,
 I hereby certify that the information given is true,
correct and complete. I understand that any falsified
correct and complete. I understand that any falsified
response may have serious consequences. I understand
response may have serious consequences. I understand
that my personal information is protected by RA 10173 or
that my personal information is protected by RA 10173 or
the Data Privacy Act of 2012 and that this form will be
the Data Privacy Act of 2012 and that this form will be
destroyed after 20 days from the date of accomplishment,
destroyed after 20 days from the date of accomplishment,
following the National Archives of the Philippines protocol.
following the National Archives of the Philippines protocol.
______________________ ________________
______________________ ________________ Name and Signature Date
Name and Signature Date

Address:Aplaya, Bauan Batangas Address:Aplaya, Bauan Batangas

(043) 984-9367 (043) 984-9367
centex.batangas@gmail.com centex.batangas@gmail.com