Date Today :_______________

HEALTH DECLARATION FORM

In line with the Workplace Prevention and Control of COVID-19, visitors and clients are required to accomplish the health symptoms questionaire daily & prior to entry. Please fill in
HONESTLY and COMPLETELY and drop it in the DROP BOX.
Employee Full Name:
Visitor Last Name First name Middle Name
Residence Address: Age:______ Sex:_______ Temp:_____________
YEScheck under
Kindly NO
the
andYES
NO Column for
your answer
a.Sore Throat
(pananakit ng lalamunan)
1. Are you
experiencing: b. Body Pains
(Pananakit ng Katawan)
C. Headache
(Pananakit ng Ulo)
d. Fever for the past few days
(Lagnat sa nakalipas na mga araw)
2. Have you worked together or stayed in the same close environment or a confirmed COVID-19 case?
(May nakasama o nakatrabahong tao na kumpirmadong may COVID-19 o may impeksyon ng corona virus)
3. Have you had contact with anyone with fever, cough, colds and sore throat for the past 14 Days?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
4. Have you travelled to any area with positive COVID-19 case?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
5. Have you ever travelled outside the Philippines in the last 14 days?
(Ikaw ba ay nakabiyahe sa labas ng Bansa sa nakalipas na 14 na araw?
Certification and Data Privacy Consent
I certify that the information I provided is true, correct and complete, I hereby authorize the Department of Education
,Division of Bukidnon (DepED Bukidnon) to collect and process the information indicated herein, in accordance with applicable laws and regulations,
for the purpose of affecting control of the COVID-19 infection.

Name and Signature Cellphone Number: _________________