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Health Form

This health form from the Celestino De Guzman Memorial National High School Stand-Alone Senior High School requires the signee to declare that in the past 14 days, their entire household was not a close contact, suspect, probable or confirmed COVID-19 case and that they are not experiencing any COVID-19 symptoms. The signee certifies the information is true and understands falsified responses have serious consequences and that their personal information is protected by the Data Privacy Act and the form will be destroyed after 20 days.

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Christine Bacordo
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47 views

Health Form

This health form from the Celestino De Guzman Memorial National High School Stand-Alone Senior High School requires the signee to declare that in the past 14 days, their entire household was not a close contact, suspect, probable or confirmed COVID-19 case and that they are not experiencing any COVID-19 symptoms. The signee certifies the information is true and understands falsified responses have serious consequences and that their personal information is protected by the Data Privacy Act and the form will be destroyed after 20 days.

Uploaded by

Christine Bacordo
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 VIII (Eastern Visayas)
Schools Division of Leyte
Barugo I District
CELESTINO DE GUZMAN MEMORIAL NATIONAL HIGH SCHOOL STAND-ALONE SENIOR HIGH SCHOOL
Minuhang, Barugo, Leyte

HEALTH FORM

I, _____________________________________________________, declare that my entire household was not considered a close contact,
suspect, probable, or confirmed COVID-19 case the past 14 days. Further, we do not experience any symptoms related to COVID-19
such as:
a. Fever d. Sore throat g. Headache
b. Cough and colds e. Diarrhea h. Loss of taste or smell
c. Difficulty of breathing f. Fatigue/ Tiredness i. Body pains
I hereby certify that the information given is true, correct and complete. I understand that 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 over Printed Name Date

Republic of the Philippines


Department of Education
Region VIII (Eastern Visayas)
Schools Division of Leyte
Barugo I District
CELESTINO DE GUZMAN MEMORIAL NATIONAL HIGH SCHOOL STAND-ALONE SENIOR HIGH SCHOOL
Minuhang, Barugo, Leyte

HEALTH FORM

I, _____________________________________________________, declare that my entire household was not considered a close contact,
suspect, probable, or confirmed COVID-19 case the past 14 days. Further, we do not experience any symptoms related to COVID-19
such as:
a. Fever d. Sore throat g. Headache
b. Cough and colds e. Diarrhea h. Loss of taste or smell
c. Difficulty of breathing f. Fatigue/ Tiredness i. Body pains
I hereby certify that the information given is true, correct and complete. I understand that 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 over Printed Name Date

Republic of the Philippines


Department of Education
Region VIII (Eastern Visayas)
Schools Division of Leyte
Barugo I District
CELESTINO DE GUZMAN MEMORIAL NATIONAL HIGH SCHOOL STAND-ALONE SENIOR HIGH SCHOOL
Minuhang, Barugo, Leyte

HEALTH FORM
I, _____________________________________________________, declare that my entire household was not considered a close contact,
suspect, probable, or confirmed COVID-19 case the past 14 days. Further, we do not experience any symptoms related to COVID-19
such as:
a. Fever d. Sore throat g. Headache
b. Cough and colds e. Diarrhea h. Loss of taste or smell
c. Difficulty of breathing f. Fatigue/ Tiredness i. Body pains
I hereby certify that the information given is true, correct and complete. I understand that 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 over Printed Name Date

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