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Health Declaration Checklist

The document is a Health Declaration Checklist from the Department of Education in the Philippines, intended to assess potential COVID-19 infection among individuals. It collects personal data and symptoms related to COVID-19, as well as recent travel history and exposure to confirmed cases. The information gathered is confidential and used solely for health assessment purposes.

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Kemberlyn Boclaras
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1 views1 page

Health Declaration Checklist

The document is a Health Declaration Checklist from the Department of Education in the Philippines, intended to assess potential COVID-19 infection among individuals. It collects personal data and symptoms related to COVID-19, as well as recent travel history and exposure to confirmed cases. The information gathered is confidential and used solely for health assessment purposes.

Uploaded by

Kemberlyn Boclaras
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

Department of Education
SOCCSKSARGEN REGION
SCHOOLS DIVISION OF SARANGANI

HEALTH DECLARATION CHECKLIST

IMPORTANT REMINDER: The information gathered on this form will be used only to determine
whether you may be infected with COVID-19. The information on this form is strictly confidential.

PERSONAL DATA:

Name:
(Last Name) (First Name) (Middle Initial)

Age: Sex: • Male Civil Status: Nationality:


• Female

Address:

Contact Number: Email Address:

Please check if you have any of the following at present or during the past 14 days:
• Fever (>37.7) • Sore throat • Diarrhea
• Cough • Headache • Body aches
• Difficulty of breathing • Loss of taste and smell • Colds/Runny nose
• Body weakness • Fatigue • Nausea/Vomiting

Please enumerate, if any, cities in the Philippines you have lived, worked, transited in the past 14 days

Please enumerate, if any, foreign countries you have lived, worked, transited in the past 14 days

Please check the appropriate box:

In the last 14 days, have you been in close contact or exposed to any • Yes • No
person suspected of COVID-19?

Were you confined in a hospital/health care facility during the • Yes • No


past 14 days?

Have you been diagnosed to have pneumonia in the past 14 days? • Yes • No

Did you visit any health facility, hospital or clinic in the past 14 days? • Yes • No

Do you have any household member/s or close contact/s who • Yes • No


are currently having fever, cough, or any respiratory problems?

In the last 14 days, have you been in contact with a COVID-19 • Yes • No
confirmed person?

Have you undergone any test for SARS-COV2 for the past 14 days? • Yes • No

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