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Health Declaration Form

Health Declaration Form

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deumaniarocelle5
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9 views

Health Declaration Form

Health Declaration Form

Uploaded by

deumaniarocelle5
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HEALTH DECLARATION FORM

IMPORTANT REMINDER: Kindly complete this health declaration form honestly. Failure to answer or
giving false information is punishable in accordance with Philippine laws.
PERSONAL INFORMATION:
De Umania Rocelle Marentes
Name:
(Last) (First) (M.I.)
Sex: [ ] Male [ *] Female Date of Birth:(dd/mm/yy) 04/02/91
Civil Status [ ]Single [ *] Married [ ]Others, pls. specify: _________________________
Occupation: Tel. /Mobile No. 09508785770
[email protected] Address in the #51 St. James St., Santol,
Email: Philippines Balagtas, Bulacan

TRAVEL HISTORY:
Arrival Date: Port of Origin:
Flight No: Seat No.:
1)
Countries visited for the past fourteen (14) days: 2)
3)
1)
Cities / municipalities in the Philippines visited for
2)
the past fourteen (14) days:
3)

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT PRESENT OR DURING THE PAST
FOURTEEN (14) DAYS:
[ ] Fever [ ] Cough [ ] Unexplained Bruising or
[ ] Headache [ ] Difficulty of Breathing Bleeding
[ ] Sore Throat [ ] Body Weakness [ ] Severe Diarrhea
[ ] Others (Specify): _____________________________

HEALTH AND SAFETY- RELATED QUESTIONS Yes No


Did you visit any hospital, clinic, or nursing home in the past fourteen (14) days?

Have you been in contact with a suspected or confirmed SARS – COV (COVID-19)
✓
patient for the past fourteen (14) days?
Do you have any household member/s, or close friend/s who have met a person currently
having fever, cough and/or respiratory problems? ✓

Data Privacy Notice: The. (name of establishment), in line with Republic Act 10173 or the Data Privacy Act of
2012, is committed to protect and secure personal information obtained in the performance of its duties. The
establishment collects the following personal information relevant in the advancement of protocols and
precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will
be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless
the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the
truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false
answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the
processing and collection of personal data only in relation to COVID-19 internal protocols.

__________________________________ _____________________
Name and Signature Date

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