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Health Dec New 1

The document is a Health Declaration Form from the University of Northern Philippines, requiring individuals to disclose their vaccination status against COVID-19. It includes a section for daily temperature recording over five days and a signature line for verification. The form emphasizes the importance of truthfulness in the information provided regarding COVID-19 symptoms and exposure.

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Lovely Ann Castro Waga

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0% found this document useful (0 votes)

6 views2 pages

Health Dec New 1

Uploaded by

Lovely Ann Castro Waga

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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HEALTH-DEC-NEW-1

Republic of the Philippines

UNIVERSITY OF NORTHERN
PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur

MEDICAL SERVICES OFFICE

HEALTH DECLARATION FORM
COLLEGE/DEPT/UNIT: _________________
Are you fully vaccinated? __YES __NO

__________________

el Coronavirus (COVID- DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

nsmit disease from
government has set DATE:________ DATE:________ DATE:________ DATE:________ DATE:________
s which the University
deration of my
wledges and agrees YES NO YES NO YES NO YES NO YES
the appropriate

he following signs

ss of smell
or are you staying
ne who is a

s document is true
:
s document is true
d I understand that Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C Temperature: ____®C
gal and public

es and Health
__________________ __________________ __________________ __________________ __________________
SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE
relevant to COVID-19 are lifted.
provided by the COVID-

y, 2700 Ilocos Sur

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Health Dec New 1

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Health Dec New 1

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HEALTH-DEC-NEW-1

Republic of the Philippines

MEDICAL SERVICES OFFICE

el Coronavirus (COVID- DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

y, 2700 Ilocos Sur

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