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Health Declaration Form

The document is a health declaration form from Bohol Island State University Candijay Campus that collects information from individuals such as their name, temperature, symptoms, and travel history to screen for potential COVID-19 infection. The form notifies individuals that their personal health information is protected and will be collected and processed to control the spread of COVID-19, in accordance with relevant privacy and emergency response laws. Individuals must provide truthful information and authorize the university to collect and process their health data for infection control purposes.

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RONARD JUSTINE GRANADA
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28 views

Health Declaration Form

The document is a health declaration form from Bohol Island State University Candijay Campus that collects information from individuals such as their name, temperature, symptoms, and travel history to screen for potential COVID-19 infection. The form notifies individuals that their personal health information is protected and will be collected and processed to control the spread of COVID-19, in accordance with relevant privacy and emergency response laws. Individuals must provide truthful information and authorize the university to collect and process their health data for infection control purposes.

Uploaded by

RONARD JUSTINE GRANADA
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

BOHOL ISLAND STATE UNIVERSITY


Candijay Campus
Cogtong, Candijay, Bohol

Health Declaration Temperature:

Name: Sex: Age:


Residence:

Yes No
1. Are you experiencing: a. Sore throat
(nakakaranas ka ba (pananakit ng lalamunan / masakit  
ng:) lumunok)
b. Body pains  
(pananakit ng katawan)
c. Headache  
(pananakit ng ulo)
d. Fever for the past few days
(Lagnat sa nakalipas na mga  
araw)
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao  
na kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore
throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat,  
ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2) lingo?)
4. Have you travelled outside of the Philippines in the last 14days?
(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)  

5. Have you travelled to any area in NCR aside from your home?  

(Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong
bahay?) Specify(Sabihin kung saan): ____________________

I hereby authorize [name of establishment], 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
11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature: Date:

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