HEALTH ASSESSMENT FORM FOR STUDENTS HWC 044-22-00

NAME: CAMPUS: CABANATUAN CAMPUS

AGE: GENDER : CONTACT NOS. YEAR/SECTION: COLLEGE/STRAND. BSN

Answer each question by placing a check (✓) mark. YES NO

1.Have you been fully vaccinated for COVID-19 during the last 2 weeks? (2 doses, except for ✔
Janssen vaccine which requires only 1 dose)

2.Have you experienced any of the following in the past 14 days

Sore throat ✔

Body pain ✔

Headache ✔

Fever ✔

Cough ✔

Colds ✔

Difficulty of breathing ✔

Diarrhea ✔
- Nausea/vomiting ✔

Tiredness ✔

Loss of taste and/or smell ✔

Skin rash ✔

Red eyes ✔

Loss of movement and/or speech ✔

Chest pain or pressure ✔

3. Have you worked together or stayed in the same close environment with a confirmed COVID-19 ✔
case or PUI who is under self-quarantine in your house or in your neighborhood?

4. Did you have any contact with anyone with fever, cough, colds, and sore throat in the past 14 days? ✔

5. Have you traveled outside of the Philippines in the last 14 days? ✔

6. Do you have any of the following conditions:

60 years old and above ✔

Ongoing pregnancy ✔

Hypertension ✔

Heart disease ✔

Diabetes mellitus ✔

Recurrent asthma attacks ✔

Chronic lung disease- ongoing PTB treatment ✔

COPD ✔

Cancer ✔

Blood dyscrasias ✔
 Chronic liver and kidney diseases ✔

Currently undergoing dialysis treatment ✔

Immunocompromised status ✔

Autoimmune disease ✔

Other Illnesses ✔

I fully understand that it is the policy of the Our Lady of Fatima University that no students regardless of status shall be allowed to
report for school on campus if any of the above mentioned conditions are present. Student may only report back to school after
following the 14-day quarantine protocol and submit a medical clearance/fit to school certificate from the School Physician before
reporting on campus.

For students in vulnerable group (VG): I fully understand that I must follow the prevailing guidelines prescribed by the
COVID-19 Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).
I attest that all the information given above are true and correct and that I may be held liable for any misinformation stated herein. I
also authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose of effecting the control of
COVID-19 infection and that my personal information are protected by RA.10173 (Data Privacy Act of 2012) and that I am
required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.

Student’s Signature Over Printed Name:

Date:
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