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Health Declaration Card: Republic of The Philippines Province of Aklan

This document is a health declaration card used by tourists arriving in the province of Aklan in the Philippines. It collects personal information such as name, date of birth, contact details, residence and travel history for COVID-19 contact tracing purposes. The card asks if the individual has experienced COVID-19 symptoms, been exposed to confirmed cases, or tested positive in the past 30 days. By signing, the individual consents to sharing this information for contact tracing and confirms the accuracy of the details provided.

Uploaded by

Mark Verdida
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52 views1 page

Health Declaration Card: Republic of The Philippines Province of Aklan

This document is a health declaration card used by tourists arriving in the province of Aklan in the Philippines. It collects personal information such as name, date of birth, contact details, residence and travel history for COVID-19 contact tracing purposes. The card asks if the individual has experienced COVID-19 symptoms, been exposed to confirmed cases, or tested positive in the past 30 days. By signing, the individual consents to sharing this information for contact tracing and confirms the accuracy of the details provided.

Uploaded by

Mark Verdida
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

Province of Aklan

HEALTH DECLARATION CARD

Tourists
-- Please read before proceeding --
In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you will be providing in this

form shall not be used for other purposes except for


COVID-19 contact-tracing activities

26c4df47-2e21-44fa-87b4-c9dcdc977c2b Arrival Date (yyyy-mm-dd): 2022-01-10

Email: markverdida16@gmail.com Contact No: 09260842326

Passport No/Valid ID Type & No: SCHOOL ID 136865150012

Name: First Name


Middle Name
Last Name

DANIEL DIAZ VILLANUEVA


Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 2009-08-22

Flight/Bus Number/Vessel Name: 5j907 Seat No: Na

Residence Address
Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): BLK 40 LOT 5 FATIMA DAANGHARI

Municipality/City
Province
Region

NAVOTAS METRO MANILA NCR


Country(ies) worked, visited and transited in the last 30 days.

NA

H E A L T H   P R O F I L E
1. Have you been sick (cough, difficulty breathing, colds, sore throat, fever) in the past 30
days?  [  ] Yes   []No

2. Have you been exposed to a confirmed case of COVID-19 ?


days?  [  ] Yes   []No

3. Have you been tested positive for COVID-19 using RT-PCR Test ?
  [  ] Yes   []No

Upon submitting, I am providing consent to sharing my information for contact tracing purposes, I confirm that the information I have
given is true, correct and complete and that
I understand failure to answer any question may have serious consequences under
Philippines laws. (Article 171 and 172 of the Revised Penal Code of the Philippines)

Signature

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