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Health Declaration Form Students

This document is a health declaration form for students of NAISUD National High School in Ibajay East, Aklan, Philippines. It asks students to provide personal information and check off whether they have experienced common COVID-19 symptoms in the last 14 days. It also asks if students have had contact with a confirmed COVID-19 case, traveled outside the country or city, or cared for a COVID-19 patient without protective equipment recently. By signing, the student certifies the information is true and understands falsified responses could have serious consequences, and that their private data will be protected and destroyed after 20 days.

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70 views

Health Declaration Form Students

This document is a health declaration form for students of NAISUD National High School in Ibajay East, Aklan, Philippines. It asks students to provide personal information and check off whether they have experienced common COVID-19 symptoms in the last 14 days. It also asks if students have had contact with a confirmed COVID-19 case, traveled outside the country or city, or cared for a COVID-19 patient without protective equipment recently. By signing, the student certifies the information is true and understands falsified responses could have serious consequences, and that their private data will be protected and destroyed after 20 days.

Uploaded by

Lois
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

Department of Education
Region VI-Western Visayas
Division of Aklan
District of Ibajay East
NAISUD NATIONAL HIGH SCHOOL

Health Declaration Form (Students)

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY):


Time (Oras):
Complete Current Address (Kasalukuyan Tirahan):
Mobile 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 No
(Oo) (Hindi)
1. Are you experiencing or did you have a. Lagnat (Fever)
any of the following in the last 14 days? b. Cough and/or colds (Ubo at/o
(Ikaw ba ay may nararanasan o Sipon)
nakaranas ng mga sumusunod na c. Body pains (Pananakit ng
sintomas sa nakaraang na araw?) katawan)
d. Sore Throat (Pananakit o
pamamaga ng lalamunan)
e. Fatigue/Tiredness (Pagkapagod)
f. Headache (Pananakit ng ulo)
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 COVID
-19 mula sa isang metro distansya or mas malapit pa at tumagal ng mahigit
15 minuto sa nakalipas na 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 maaaring o kumpirmadong pasyente na may
COVID-19 ng hindi nakasuot ng tamang PPE (Personal Protective
Equipment) sa nakalipas na 14 araw?)
4. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay
nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?)
5. Have you traveled outside the current city/municipality where you reside? (Ikaw
ba ay nagbiyahe sa labas ng iyong sa lubas 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 may 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.
__________________________
Name and Signature

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