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Health Declaration Health Declaration: Body Temperature: - Body Temperature

This health declaration form collects information from examinees such as name, age, symptoms experienced within the last 14 days, and contact number. It states that the information provided is true under oath and can be collected and processed by the Civil Service Commission to control the spread of COVID-19. It also notes that personal information is protected by law but must be provided truthfully, as false information could impact public health. Finally, it specifies that contact details may be shared with local authorities for contact tracing if the examinee tests positive for COVID-19 within 14 days of the exam.

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Rexenne Beniga
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90 views

Health Declaration Health Declaration: Body Temperature: - Body Temperature

This health declaration form collects information from examinees such as name, age, symptoms experienced within the last 14 days, and contact number. It states that the information provided is true under oath and can be collected and processed by the Civil Service Commission to control the spread of COVID-19. It also notes that personal information is protected by law but must be provided truthfully, as false information could impact public health. Finally, it specifies that contact details may be shared with local authorities for contact tracing if the examinee tests positive for COVID-19 within 14 days of the exam.

Uploaded by

Rexenne Beniga
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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(Revised, May 2022) (Revised, May 2022)

HEALTH DECLARATION HEALTH DECLARATION

Body Temperature: ___________________ Body Temperature: ___________________


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

Date: ________________________ Date: ________________________

Full Name: _____________________________ Sex: ______ Age: ______ Full Name: _____________________________ Sex: ______ Age: ______

Residence: _____________________________________________________ Residence: _____________________________________________________

Contact Number/s: _______________________________________________ Contact Number/s: _______________________________________________

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

I declare under oath that I personally accomplished this Health Declaration form. Further, 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 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. 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 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 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 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 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 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 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 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 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. concerned, provide my necessary/pertinent information for contact tracing.

Signature: __________________________________ Signature: __________________________________

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