‘NORSU HEAT.TH DECLARATIONICONTACT TRACING FORM (Gi Commencement Exerase 2023) NAME: AGE:_SEX: DATE: ADDRESS: CONTACT #: COLLEGE: | VACCINATION STATUS (Please check): (__)Fully Vaccinated (With or withoutBoostet)(_) Partially Vaccinated Unvaccinated | ‘NOTE; Unyucsinated & partially vaccinated persons aremot allowed to physically join the face-to-face activity as per instruction oflacal ATR. | | ____ Not allowed als i with any ofthe “VES” answer below. | ‘By enering the university campusigymnasium, attest tothe flowing (Please Pula Check Maik on the Bank) L) Yes No__: Da,youhave cough, colds oso sense of astlsmell, fever, sore that, LBM, difficulty of breathing or any other respira symptoms so Une nesen& eh pas 7 daystfr fully vaceinatedVin the pat 4 dys((or unvaccinated & paraly vaccinated)? 2) Yes__No__: Areyou presctly sick (including any contagious diseases)? 3) Yes No: Are you raving dicct cae fo a probable ot coatrmed COVID-19 ease? 4) Yes No___: Do youthave direct physical contac, or lived, worked, or transacted in close proximity (es han mete) for more han 15 minutes wih a Primary (* degree) Close Contact, Probable ot Confirmed COVID- 19 case in the past 7 days Fr filly ‘vaccinatdyin the past 14 days(or unvaccinated & partaly vaccinated)? 5) Yes ‘Ate you diagnosed with COVID-9 in the past T day fllyvaccinatcdfin the past 14 aystunvaccinaepailly)? 6) Yes ‘Are you awaiting say COVID-19 test result that was done on you forthe past 7 days? 7) Yes Have you traveled intemationally or abroad within the pas 7 days? Faltowing the above pronouncements hereby declare that Tam ling the trath fer the safety of mse and the people around me nie the siversitycampu/gymnasiam. cunre === 7 [NORSU HEALTH DECLARATION/CONTACT TRACING FORM (64% Commencement Exercise 2022) NAME: AGE:_SEX: DATE: ADDRESS: CONTACT # couece: VACCINATION STATUS (Please check): (__)Fully Vaccinated (Withor without Boost) (_)Partally Vaccinated (_)Unvaccinated NOTE; Unvaccinated& partially vaceinated persons are not allowed to physically join the face-to-face aetivity as per instruction oflocal ATF, [Not allowed also if with any of the “VES* answer below. Tiy entering the university campos/aymnasium, Tatts tothe following (Pease Pala Check Nak oa the Blane 1) Yes___No__: Doyouhave cough, colds, loss of suse of tustelsmel, eve, sre throat, LEM, dificulty of breathing or anyother respiratory symptoms as ofthe present & in the pas days(frfllyvaccinatedin the past 14 days(for uavaccinated & patally vaccinated)? 2) Yer__ ‘Ace you presally sick (neheding any contagious diseases)? | 3) Yes ‘Are you providing direct care fra probable or confirmed COVID-19 case? 4) Yes ‘Do you have direct physica eta, olive, worked, or wansscted in clase proximity (les than mete) For more than 15 minutes wit Primary ( depree) Close Coataet, Probable or Confiemed COVID-19 casein Ue past 7 daystfor fully ‘vaccine he past daysor unvaccinated & pally vaccinated)? | 5) Yes___No___: Are you diagnosed with COVID-19in the past 7 days( lly Vaccinatodin the past 14 days(uavaccnatedparaly)? | 5) Yes No__ Are you awaiting any COVID-19 est esl tht was dane on yu for the pas 7 ays? 7) Yes___No__: Have you taveed intemationally or abroad within the past 7 days? Following the above pronouncements, I hereby declare that am telling the ruth forthe safety of myself and the people around me inside the university campus/gymnasiom. cutters — See curttere — NORSU IKEAL-TH-DECLARATION/ CONTACT TRACING FORM (64! Commencement Exerdse 2022) NAME: (poe px eee DATE: ADDRESS: CONTACT #: COLLEGE: VACCINATION STATUS (Please check): (__)Fully Vaccinated (Wh or without Booster) (__)Partally Vaccinated (__)Unyaceinated NOTE: Unvaecinated & partially vaceinated persons are nat allowed to physically join the face-to-face activity as per instruction of local [ATF [Not allowed also if with any ofthe "YES" answer low. ‘By entering the university campus/gymnasiam, Tattst cw the following (Plewse Put a Cheek Mark on the Blank): L) Yes___No___ Dayou have cough, cold, loss of sense of tastelsmel, ever, sore throat, LBM, difcaltyof breathing o any other respiratory symptoms a ofthe present & inthe past 7 daystor filly vaccinatedin the past 14 days(for unvaccinated partially vaccinated)? 2) Yes___No__: Are you presently sick including any contagious diseases)? 3) Yes No___ Are you providing direct care for a probable or confirmed COVID-19 case? | 4) Yer No: Doyouthave direct physical contac, o ved, worked, or wansacted in clase proximity (less than meter for move than 15 minutes wid Primary (" degree) Close Contact, Probable or Confirmed COVID-19 casein the pas 7 dastfr fully ‘vaccinate the past 14 days(foruwaceinated & partially vaccinated)? | 5) Yes__ No__+ Areyou diagnosed with COVID-19 in th pas 7 aystflly vaccnstein the pst 14 days(unaceinatd/arially)? 6) Yee No_+ Are you awaiting any COVID-I9 tex rest hat was dnc on Yu fr the pst 7 ays? 1) Yes No Have you taveled intatonlly or abroad within the past 7 ays? Following the above pronouncements, {hereby declare that Tamm telling the truth forthe safty of myscifand the people around me inside the univers campor’gynnasiui, ‘Signature