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Department of Education: Health Declaration Form

The Department of Education Schools Division of Davao City is implementing a strict "NO FACE MASK, NO ENTRY" policy for all individuals entering testing centers. All individuals must wear a face mask at all times while inside testing center premises. The document also provides a health declaration form that collects an individual's personal information, health status, travel history, and potential exposure to COVID-19. By signing the form, individuals consent to sharing their personal information only as it relates to COVID-19 protocols.

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ernesto Sumandang
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35 views1 page

Department of Education: Health Declaration Form

The Department of Education Schools Division of Davao City is implementing a strict "NO FACE MASK, NO ENTRY" policy for all individuals entering testing centers. All individuals must wear a face mask at all times while inside testing center premises. The document also provides a health declaration form that collects an individual's personal information, health status, travel history, and potential exposure to COVID-19. By signing the form, individuals consent to sharing their personal information only as it relates to COVID-19 protocols.

Uploaded by

ernesto Sumandang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Education
SCHOOLS DIVISION OF DAVAO CITY

ANNEX B

NOTICE: The Department of Education Schools Division of Davao City is strictly implementing a
“NO FACE MASK, NO ENTRY” policy. Wear your face mask at all times while inside the testing center
premises.

HEALTH DECLARATION FORM

Full Name:
Last Name First Name Middle Name
Nationality: Sex: Age: Contact Number:
Email Address:
Present Address:
Foreign countries you have worked, visited, transited in the past 14
days
Cities in the Philippines you have worked, lived o transited in the
past 14 day
Have you been sick in the past 30 days? Hospital “Yes”, please describe condition: No
visited, if any?
In the last 14 days, did you have any of the following: “Yes”, please specify: No
fever or chills, cough, shortness of breath or difficulty in
breathing, fatigue, muscle or body aches, headache,
loss of taste or smell, sore throat, congestion or runny
nose, sore eyes, nausea or vomiting, diarrhea or
cutaneous (skin) manifestation/lesion especially in
children?
In the last 14 days, have you been in close contact or “Yes”, please describe circumstance: No
exposed to any person suspected of or confirmed with
COVID-19?
In the last 14 days, have you been in close contact with “Yes”, please describe circumstance: No
farm animals or exposed to wild animals?
Declaration and Data Privacy Consent Form:

This information I have given is true, correct and complete. I understand that failure to answer any question
or giving false answer can be penalized in accordance with law.

I voluntarily and freely consent to the collection and sharing of the above personal information only in
relation to the COVID-19 internal protocols.

________________________________ _________________________
Name and Signature Date

Please be advised that the above information shall only be used in relation to the COVID internal protocols in
accordance with the Data Privacy Act. For any concerns you may contact davaocity.division@deped.gov.ph.

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