Health Declaration Form

NAME

AGE

SEX

CONTACT NUMBER

ADDRESS

PROVINCE

1. HAVE YOU BEEN SICK IN THE PAST 14 DAYS ?
2. HAVE YOU TRAVELLED OUTSIDE OF THE PHILIPPINES IN THE LAST 14 DAYS ?

IF YES PLEASE SPECIFY THE PLACE VISITED :

3. HAVE YOU TRAVELLED TO ANY AREA IN NCR ASIDE FROM YOUR HOME ?

IF YES PLEASE SPECIFY THE PLACE VISITED :

4. DID YOU HAVE ANY CLOSE CONTACT OR HAVED LIVED WITH A PERSON EXHIBITING SYMPTOMS OR DIAGNOSED AS CONFIRMED CASE OF COVID 19 ?

5. DID YOU HAVE ANY OF THE FOLLOWING IN THE LAST 14 DAYS ?

FEVER

COUGH

COLDS

SORE THROATS

6. TEMPERATURE READING :

 * The information I have given is true, correct and complete. I understand failure to answer any question may have serious consequences.

( Article 171 and 172 of the Revised Penal Code of the Philippines ) and RA11332

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