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OHDC Mark

This document is a health declaration card for tourists arriving in the province of Aklan, Philippines. It collects personal information such as name, passport number, contact details, flight information, residence address in the Philippines, and health profile questions regarding COVID-19 symptoms, exposure, and testing. By submitting the form, the individual consents to sharing their information for COVID-19 contact tracing purposes and confirms the information is true under Philippines law.

Uploaded by

Carlo Gonzalo Garcia
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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49 views2 pages

OHDC Mark

This document is a health declaration card for tourists arriving in the province of Aklan, Philippines. It collects personal information such as name, passport number, contact details, flight information, residence address in the Philippines, and health profile questions regarding COVID-19 symptoms, exposure, and testing. By submitting the form, the individual consents to sharing their information for COVID-19 contact tracing purposes and confirms the information is true under Philippines law.

Uploaded by

Carlo Gonzalo Garcia
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
Verification ID: 4D874DF3-DDC4-49CB-BCAB-CB65C4BA22F2; Date/Time: 2022-05-19 15:33:28; User ID: 1
-- 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
:
9cb8845f-86f7-4626-8f26-4914a86194c5 Arrival Date (yyyy-mm-dd): 2022-05-20

Email: chinolerin14@gmail.com Contact No: 09618138784

Passport No/Valid ID Type & No: D22-19-007003

Name: First Name


RODNYMARK
Middle Name
LERIN
Last Name
FEENANDEZ
Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 1993-08-19

Flight/Bus Number/Vessel Name: 5J907 Seat No: -

Residence Address Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): B9 L17 PH1A SAN LORENZO SOUTH BRGY MALITLIT

Municipality/City Province Region


STA ROSA LAGUNA IV-A
Country(ies) worked, visited and transited in the last 30 days.

NA

HEALTH PROFILE
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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