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Household Health Declaration

This document contains a household health declaration form from Bongbongan II Elementary School. The form requires parents/guardians to declare that no one in their household has been a close contact or suspected, probable or confirmed case of COVID-19 in the past 14 days. It also requires them to confirm that no one in the household is experiencing COVID-19 symptoms. Parents must sign and date the form, certifying that the information is true, and understanding that any falsified information could have serious consequences. Personal information on the form is protected by the Data Privacy Act and the form will be destroyed after 20 days.

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Bongbongan Dos ES
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31 views3 pages

Household Health Declaration

This document contains a household health declaration form from Bongbongan II Elementary School. The form requires parents/guardians to declare that no one in their household has been a close contact or suspected, probable or confirmed case of COVID-19 in the past 14 days. It also requires them to confirm that no one in the household is experiencing COVID-19 symptoms. Parents must sign and date the form, certifying that the information is true, and understanding that any falsified information could have serious consequences. Personal information on the form is protected by the Data Privacy Act and the form will be destroyed after 20 days.

Uploaded by

Bongbongan Dos ES
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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Department of Education Department of Education

Region VI – Western Visayas Region VI – Western Visayas


Schools Division of Antique Schools Division of Antique
District of Sibalom North District of Sibalom North
BONGBONGAN II ELEMENTARY SCHOOL BONGBONGAN II ELEMENTARY SCHOOL

HOUSEHOLD HEALTH DECLATION FORM HOUSEHOLD HEALTH DECLATION FORM


I, _____________________________ (Name of Parent/Guardian), declare that my entire I, _____________________________ (Name of Parent/Guardian), declare that my entire
household was not considered a close contact, suspect, probable, or confirmed COVID- household was not considered a close contact, suspect, probable, or confirmed COVID-
19 case the past 14 days. Further, we do not experience any symptoms related to 19 case the past 14 days. Further, we do not experience any symptoms related to
COVID-19 such as: COVID-19 such as:
a. Fever f. Fatigue/ Tiredness a. Fever f. Fatigue/ Tiredness
b. Cough and colds g. Headache b. Cough and colds g. Headache
c. Difficulty of breathing h. Loss of taste or smell c. Difficulty of breathing h. Loss of taste or smell
d. Sore throat i. Body pains d. Sore throat i. Body pains
e. Diarrhea e. Diarrhea

I hereby certify that the information given is true, correct and complete. I I hereby certify that the information given is true, correct and complete. I
understand that any falsified response may have serious consequences. I understand that understand that any falsified response may have serious consequences. I understand that
my personal information is protected by RA 10173 or the Data Privacy Act of 2012 and my personal information is protected by RA 10173 or the Data Privacy Act of 2012 and
that this form will be destroyed after 20 days from the date of accomplishment, that this form will be destroyed after 20 days from the date of accomplishment,
following the National Archives of the Philippines protocol. following the National Archives of the Philippines protocol.

________________________________ __________________ ________________________________ __________________


Name and Signature of Parent/Guardian Date Name and Signature of Parent/Guardian Date

*Per DOH DM 2020-0512, testing is performed when there is a particular reason to suspect that an *Per DOH DM 2020-0512, testing is performed when there is a particular reason to suspect that an
individual may be infected after symptoms-based screening. individual may be infected after symptoms-based screening.
Department of Education Department of Education
Region VI – Western Visayas Region VI – Western Visayas
Schools Division of Antique Schools Division of Antique
District of Sibalom North District of Sibalom North
BONGBONGAN II ELEMENTARY SCHOOL BONGBONGAN II ELEMENTARY SCHOOL

HEALTH DECLATION FORM HEALTH DECLATION FORM


I, _____________________________ (Name of Parent/Guardian), declare that my entire I, _____________________________ (Name of Parent/Guardian), declare that my entire
household was not considered a close contact, suspect, probable, or confirmed COVID- household was not considered a close contact, suspect, probable, or confirmed COVID-
19 case the past 14 days. Further, we do not experience any symptoms related to 19 case the past 14 days. Further, we do not experience any symptoms related to
COVID-19 such as: COVID-19 such as:
a. Fever f. Fatigue/ Tiredness a. Fever f. Fatigue/ Tiredness
b. Cough and colds g. Headache b. Cough and colds g. Headache
c. Difficulty of breathing h. Loss of taste or smell c. Difficulty of breathing h. Loss of taste or smell
d. Sore throat i. Body pains d. Sore throat i. Body pains
e. Diarrhea e. Diarrhea

I hereby certify that the information given is true, correct and complete. I I hereby certify that the information given is true, correct and complete. I
understand that any falsified response may have serious consequences. I understand that understand that any falsified response may have serious consequences. I understand that
my personal information is protected by RA 10173 or the Data Privacy Act of 2012 and my personal information is protected by RA 10173 or the Data Privacy Act of 2012 and
that this form will be destroyed after 20 days from the date of accomplishment, that this form will be destroyed after 20 days from the date of accomplishment,
following the National Archives of the Philippines protocol. following the National Archives of the Philippines protocol.

________________________________ __________________ ________________________________ __________________


Name and Signature of Parent/Guardian Date Name and Signature of Parent/Guardian Date

*Per DOH DM 2020-0512, testing is performed when there is a particular reason to suspect that an *Per DOH DM 2020-0512, testing is performed when there is a particular reason to suspect that an
individual may be infected after symptoms-based screening. individual may be infected after symptoms-based screening.

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