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Inocencio School Student Health Declaration Sheet

This document contains a student health declaration form regarding COVID-19. The form asks if the student or anyone they have been in contact with has experienced COVID-19 symptoms or tested positive for COVID-19 in the past 21 days. It also asks if the student is currently experiencing symptoms like fever, cough, or loss of taste/smell. The parent must declare that the student has not had COVID-19 in the past 14 days, has not been exposed to anyone with COVID-19, and is healthy enough to attend limited in-person classes without risking the health of others. The parent signs the form and the student's temperature is recorded.

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Crunchy Fried Rice
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43 views2 pages

Inocencio School Student Health Declaration Sheet

This document contains a student health declaration form regarding COVID-19. The form asks if the student or anyone they have been in contact with has experienced COVID-19 symptoms or tested positive for COVID-19 in the past 21 days. It also asks if the student is currently experiencing symptoms like fever, cough, or loss of taste/smell. The parent must declare that the student has not had COVID-19 in the past 14 days, has not been exposed to anyone with COVID-19, and is healthy enough to attend limited in-person classes without risking the health of others. The parent signs the form and the student's temperature is recorded.

Uploaded by

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

DEPED-NCR DEPED-NCR DEPED-NCR


SANGAY NG LUNGSOD NG PASIG SANGAY NG LUNGSOD NG PASIG SANGAY NG LUNGSOD NG PASIG
INOCENCIO SCHOOL INC. INOCENCIO SCHOOL INC. INOCENCIO SCHOOL INC.

STUDENT HEALTH DECLARATION FORM STUDENT HEALTH DECLARATION FORM STUDENT HEALTH DECLARATION FORM

DATE: ___________________ DATE: ___________________ DATE: ___________________


STUDENT NAME: __________________________________________ STUDENT NAME: ____________________________________________ STUDENT NAME: ___________________________________________
GRADE & SECTION: ________________________________________ GRADE & SECTION: _________________________________________ GRADE & SECTION: _________________________________________
RELATION TO STUDENT: ____________________________________ RELATION TO STUDENT: _____________________________________ RELATION TO STUDENT: _____________________________________

Did you visit countries or cities in the past 21 days? Did you visit countries or cities in the past 21 days? Did you visit countries or cities in the past 21 days?

Have you had contact with people with COVID-19 or with people who Have you had contact with people with COVID-19 or with people who Have you had contact with people with COVID-19 or with people who
are suspected with COVID-19 in the past 21 days? are suspected with COVID-19 in the past 21 days? are suspected with COVID-19 in the past 21 days?

Symptoms: Symptoms: Symptoms:


• Fever of 37.5 or greater • Fever of 37.5 or greater • Fever of 37.5 or greater
• Headache • Headache • Headache
• Cough • Cough • Cough
• Muscle pains • Muscle pains • Muscle pains
• Chills • Chills • Chills
• Sore throat • Sore throat • Sore throat
• Shortness of breath • Shortness of breath • Shortness of breath
• Loss of taste or smell • Loss of taste or smell • Loss of taste or smell
(not severe) (not severe) (not severe)
• Nausea, Vomiting or diarrhea • Nausea, Vomiting or diarrhea • Nausea, Vomiting or diarrhea

Is the student experiencing any of the symptoms listed above today or Is the student experiencing any of the symptoms listed above today or Is the student experiencing any of the symptoms listed above today or
has the student experienced any within the last 24 hours? has the student experienced any within the last 24 hours? has the student experienced any within the last 24 hours?

I hereby declare that ____________________________ has neither I hereby declare that ____________________________ has neither I hereby declare that ____________________________ has neither
suffered from Covid -19 nor exhibited any symptoms related to the said suffered from Covid -19 nor exhibited any symptoms related to the said suffered from Covid -19 nor exhibited any symptoms related to the said
disease for the last 14 days prior to this date. Further, to the best of my disease for the last 14 days prior to this date. Further, to the best of my disease for the last 14 days prior to this date. Further, to the best of my
knowledge, he/she has never been in association or close proximity with knowledge, he/she has never been in association or close proximity with knowledge, he/she has never been in association or close proximity with
anyone who has shown symptoms or is known to have suffered the said anyone who has shown symptoms or is known to have suffered the said anyone who has shown symptoms or is known to have suffered the said
disease within the same period of time, and that he/she is healthy disease within the same period of time, and that he/she is healthy disease within the same period of time, and that he/she is healthy
enough to study under the Limited Face-to-Face learning modality enough to study under the Limited Face-to-Face learning modality enough to study under the Limited Face-to-Face learning modality
without being a risk to others. without being a risk to others. without being a risk to others.
I hereby issue this declaration this ____ day of_________, 2022. I hereby issue this declaration this ____ day of_________, 2022. I hereby issue this declaration this ____ day of_________, 2022.

_______________________________________ _______________________________________ _______________________________________


Signature over printed name of parent/guardian Signature over printed name of parent/guardian Signature over printed name of parent/guardian

STUDENT’S TEMPERATURE: _______________ STUDENT’S TEMPERATURE: _______________ STUDENT’S TEMPERATURE: _______________

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