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HEALTH DECLARATION FORM For Covid

This health declaration form from Buguey South Central School collects personal information such as name, age, symptoms experienced, potential contact with COVID-19 patients, and area of residence to prevent the spread of COVID-19 at the upcoming Division Schools Press Conference at Penablanca National High School. Participants must sign to consent to sharing this information and declare that their answers are truthful.

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Renato Urolaza Ignacio
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304 views2 pages

HEALTH DECLARATION FORM For Covid

This health declaration form from Buguey South Central School collects personal information such as name, age, symptoms experienced, potential contact with COVID-19 patients, and area of residence to prevent the spread of COVID-19 at the upcoming Division Schools Press Conference at Penablanca National High School. Participants must sign to consent to sharing this information and declare that their answers are truthful.

Uploaded by

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

Department of Education

BUGUEY SOUTH CENTRAL SCHOOL

HEALTH DECLARATION FORM

To prevent the spread of COVID-19 and reduce the risk of exposure among the
participants of this year’s Division Schools Press Conference, this health
declaration form should be accomplished.

Name:

Age: Sex:

Home Address:

CP#

Venue: PENABLANCA NATIONAL HIGH SCHOOL

Purpose: TO ATTEND DIVISION JOURNALYMPICS

Temperature Reading: Date: Time:

1. In the past 14 days, which of the following symptom/s have you


experienced? Please check relevant boxes:
Yes No
Fever Dry Cough
Sore Throat Tiredness
Diarrhea Shortness of breath
Body Aches Runny
Headache Others: NONE OF THE ABOVE

2. Have you been in contact with a confirmed COVID-19 patient in the


past 14 days?
Yes No

3. Have you been residing in areas identified as high-risk of COVID-


19? Yes No
If yes, please specify the area: ___________________________________.
Declaration and Data Privacy Consent Form:

The information I have given are true, correct, and complete. I understand
that failure to answer any question or giving false answer can be penalized
in accordance with existing laws.

I voluntarily and freely consent to the collection and sharing of the above
personal information for the purpose stated herein.

____________________________ _____________
Signature over Printed Name Date

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