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Health Declaration Form

This document is a health declaration form used in the Philippines to screen individuals for COVID-19 symptoms and exposure. It collects personal information like name, address, and contact details. It asks if the individual has experienced common COVID-19 symptoms in the last 14 days or had close contact with a confirmed case. It also asks about travel history. The individual certifies the information is true and consents to having their personal data protected per privacy laws, with the form being destroyed after 20 days.

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Ginalyn Diloy
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64 views

Health Declaration Form

This document is a health declaration form used in the Philippines to screen individuals for COVID-19 symptoms and exposure. It collects personal information like name, address, and contact details. It asks if the individual has experienced common COVID-19 symptoms in the last 14 days or had close contact with a confirmed case. It also asks about travel history. The individual certifies the information is true and consents to having their personal data protected per privacy laws, with the form being destroyed after 20 days.

Uploaded by

Ginalyn Diloy
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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Republic of the Philippines

Province of Leyte
Municipality of Pastrana
Barangay ________________

HEALTH DECLARATION FORM


Date (Petsa) (MM/DD/VY):
Full Name (Buong Pangalan):
Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng telepono):
Email Address:

Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)
Yes (Oo) No (Hindi)
1. Are you experiencing a) Fever (Lagnat)
or did you have any of b) Cough and/or Colds (Ubo at/o Sipon)
the following in the last
c) Body pains (Pananakit ng katawan)
14 days? (lkaw ba ay
may nararanasan o d) Sore Throat (Pananakit o pamamaga ng
nakaranas ng mga lalamunan)
sumusunod na sintomas e) Fatigue/Tiredness (Pagkapagod)
sa nakaraang 14 na f) Headache (Pananakit ng ulo)
araw?) g) Diarrhea (Pagtatae)
h) Loss of taste or smell (Nawalan ng
panlasa o pang-amoy)
i) Difficulty of breathing (Pagkahapo o hirap
sa paghinga)
2. Have you had face-to-face contact with a probable or confirmed
COVID-19 case within 1 meter and for more than 15 minutes for the past
14 days? (May nakasalamuha ka ba na maaaring o kumpirmadong
pasyente na may COV/D-19 mu/a sa isang metrong distansya or mas
malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 araw?)
3. Have you provided direct care for a patient with probable or confirmed
COVID-19 case without using proper "Personal Protective Equipment
(PPE)" for the past 14 days? (Nag-alaga ka ba ng maaring o
kumpirmadong pasyente na may COV/D-19 ng hindi nakasuot ng tamang
PPE (Personal Protective Equipment) sa nakalipas na 14 araw?)
4. Have you traveled outside the Philippines in the last 14 days? (lkaw ba
ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
5. Have you traveled outside the current city/municipality where you
reside? {lkaw ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo?) If
yes, specify which city/municipality you went to (Sabihin kung saan):
__________________

I hereby certify that the information given is true, correct and complete. I understand that failure to
answer any question or any falsified response may have serious consequences. I understand that my

personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that this form will
be destroyed after 20 days from the date of accomplishment, following the National Archives of the
Philippines protocol.

Signature (Lagda): ________________________

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