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Health Declaration Form

This health declaration document collects information from an examinee such as name, contact details, residence, and body temperature. It asks if the examinee is currently experiencing or has experienced within the last 14 days symptoms related to COVID-19 such as fever, cough, sore throat, loss of taste or smell. It also asks if the examinee has been in contact with a confirmed COVID-19 case, is living with someone awaiting COVID-19 test results, has been in contact with someone showing symptoms in the last 2 weeks, or has traveled outside the Philippines in the last 14 days. The examinee declares that the information provided is true and correct and authorizes the collection of personal information for COVID-19

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85 views

Health Declaration Form

This health declaration document collects information from an examinee such as name, contact details, residence, and body temperature. It asks if the examinee is currently experiencing or has experienced within the last 14 days symptoms related to COVID-19 such as fever, cough, sore throat, loss of taste or smell. It also asks if the examinee has been in contact with a confirmed COVID-19 case, is living with someone awaiting COVID-19 test results, has been in contact with someone showing symptoms in the last 2 weeks, or has traveled outside the Philippines in the last 14 days. The examinee declares that the information provided is true and correct and authorizes the collection of personal information for COVID-19

Uploaded by

Nrc A.
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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HEALTH DECLARATION

Body Temperature: ___________________


(Instruction to leave blank as temp will be supplied on the
day of exam after scanning)
Date: ________________________

Full Name: ____________________________________________________ Sex: _______ Age: _______

Residence: ________________________________________________________________________________

Contact Number/s: __________________________________________________________________________

YES NO
Symptoms (Mga sintomas)
(Oo) (Hindi)
1. Are you currently a. Sore throat (Pananakit ng lalamunan/masakit lumunok)
experiencing
b. Shortness of Breath (Hirap sa paghinga)
symptoms, or have
experienced, within c. Body pains (Pananakit ng katawan)
the last 14 days:
d. Headache (Pananakit ng ulo)
(Kasalukuyan ka bang e. Fever for the past few days (Lagnat sa mga nakalipas na araw)
nakakaranas ng sintomas
o nakaranas sa huling 14 f. Loss of taste or smell (Pagkawala ng panlasa o pang-amoy)
na araw)
g. Cough and/or cold (Ubo at/o sipon)
h. Diarrhea (Pagtatae)

2. Have you worked together or stayed in the same household/ close environment with a
confirmed COVID-19 case?
(May nakasama ka ba or nakatrabahong tao na kumpimadong COVID-19 case/may impeksyon ng
COVID-19?)

3. Are you living with a household member who is currently waiting for results of his/her
swab test/ COVID-19 test?
(Ikaw ba ay may kasama sa bahay na nag-aantay ng resulta ng swab test/ COVID-19 test?)

4. Have you had any contact with anyone or living with household member with fever,
cough, colds, sore throat, loss of taste or smell in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng
dalawang (2) linggo?)

5. Have you travelled outside of the Philippines within the last 14 days?
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

I declare under oath that I personally accomplished this Health Declaration form. Further, I declare that the
information given are true, correct, and complete statements pursuant to the provisions of pertinent laws, rules,
and regulations of the Republic of the Philippines.

I hereby authorize the CIVIL SERVICE COMMISSION (CSC), to collect and process the data indicated herein for
the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected
by RA 10173, Data Privacy Act of 2012, and that I am required by RA No. 11469, Bayanihan to Heal as One Act,
as amended by RA 11494, to provide truthful information. Further, I understand that any false information may
have serious public health implications and may be subjected to legal consequences. Finally, I understand that, in
case I would test positive for COVID-19 within 14 days after the exam day, the CSC shall, upon request of the
LGU/Barangay concerned, provide my necessary/pertinent information for contact tracing.

Signature: __________________________________

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