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Health Declaration Form - 1606903543

This health declaration form asks individuals for information including name, age, contact details, address, and temperature. It inquires about travel history, contact with COVID-19 cases, and symptoms experienced in the last 14 days. It seeks authorization to collect this data for COVID-19 control and requires acknowledgment of legal implications for providing untruthful information.

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Patrick Gregorio
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39 views

Health Declaration Form - 1606903543

This health declaration form asks individuals for information including name, age, contact details, address, and temperature. It inquires about travel history, contact with COVID-19 cases, and symptoms experienced in the last 14 days. It seeks authorization to collect this data for COVID-19 control and requires acknowledgment of legal implications for providing untruthful information.

Uploaded by

Patrick Gregorio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Health Declaration Form o None of the above

Name: _________________________________
6. Is there anyone in your household who has
Age: ____ Contact No.: ___________________ exhibited any of the symptoms in question
no. 6 within the last 14 days? 
Address: _______________________________ o Yes
o No
_______________________________________

Temperature: (to be checked before entering the 7. Have you tested POSITIVE for COVID-19
cinema) ________________ within the last 14 days (testing may either
be through oral/nasal swab or blood
Date: __________ extraction)? 
o Yes
Time: __________
o No
1. Are you below 18 years old? 
o Yes 8. I hereby authorize New Life Southwoods to
o No collect and process the data indicated
herein for the purpose of implementing
2. Are you above 65 years old?  control and/containment of COVID-19. I
o Yes understand that my personal information is
o No protected by RA 10173, Data Privacy Act of
2012, and that I am required by RA 11469,
3. Did you travel abroad within the last 14 Bayanihan to Heal as One Act, to provide
days?  truthful information. That I am aware of the
o Yes implications if any statement is not honestly
o No stated and that there are legal actions to be
taken in responsibility to myself and the
company I represent. 
4. Within the last 14 days, have you had
o Yes
contact with or exposure to a confirmed or
probable case of COVID19? 
o Yes
o No

5. In the last 14 days, did you have AT LEAST


ONE of the following symptoms: 
o Fever
o Cough
o Colds
o Sore Throat
o Shortness of Breath/Difficulty in
Breathing
o Diarrhea
o Weakness or fatigue
o Vomiting

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