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    Deped - Health Declaration Form 2020

    Uploaded by

    LHEYA AQUINO
    This is a health declaration form from the Department of Education Region V Schools Division Office of Camarines Sur. The 3 sentence summary is: The form collects information such as name, address, contact details, temperature, and answers to questions about experiencing COVID-19 symptoms or having contact with confirmed cases. By signing, the individual authorizes the department to collect and process the personal data for controlling the COVID-19 infection while acknowledging their requirement to provide truthful information under relevant laws. The form is to be completed prior to entering a school testing center in Camarines Sur, Philippines.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Deped - Health Declaration Form 2020

    Uploaded by

    LHEYA AQUINO
    5K views1 page
    This is a health declaration form from the Department of Education Region V Schools Division Office of Camarines Sur. The 3 sentence summary is: The form collects information such as name, address, contact details, temperature, and answers to questions about experiencing COVID-19 symptoms or having contact with confirmed cases. By signing, the individual authorizes the department to collect and process the personal data for controlling the COVID-19 infection while acknowledging their requirement to provide truthful information under relevant laws. The form is to be completed prior to entering a school testing center in Camarines Sur, Philippines.

    Original Description:

    Form 2020

    Original Title

    DEPED_HEALTH-DECLARATION-FORM-2020

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    This is a health declaration form from the Department of Education Region V Schools Division Office of Camarines Sur. The 3 sentence summary is: The form collects information such as name, address, contact details, temperature, and answers to questions about experiencing COVID-19 symptoms or having contact with confirmed cases. By signing, the individual authorizes the department to collect and process the personal data for controlling the COVID-19 infection while acknowledging their requirement to provide truthful information under relevant laws. The form is to be completed prior to entering a school testing center in Camarines Sur, Philippines.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    5K views1 page

    Deped - Health Declaration Form 2020

    Uploaded by

    LHEYA AQUINO
    This is a health declaration form from the Department of Education Region V Schools Division Office of Camarines Sur. The 3 sentence summary is: The form collects information such as name, address, contact details, temperature, and answers to questions about experiencing COVID-19 symptoms or having contact with confirmed cases. By signing, the individual authorizes the department to collect and process the personal data for controlling the COVID-19 infection while acknowledging their requirement to provide truthful information under relevant laws. The form is to be completed prior to entering a school testing center in Camarines Sur, Philippines.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Republic of the Philippines

    Department of Education
    REGION V
    SCHOOLS DIVISION OFFICE OF CAMARINES SUR
    Enclosure 2

    Health Declaration Form Temperature: ______

    Name:______________________________________________________ Sex: _____________ Age: _____

    Residence: __________________________________________________ Contact #:__________________

    Barangay: __________________________________________________

    School Name where you applied for: _____________________________________ Schedule (Date & Time):__________________
    _____________________________________ __________________
    School Testing Center: _________________________________________

    Yes No
    1. Are you experiencing: a. Sore throat
    (nakakaranas ka ba ng ) (pananakit ng lalamunan/masakit 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 infection ng coronavirus
    3. Have you have 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 14 days? (Ikaw ba ay
    nagbiyahe 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, Region IV-A and Region VII bukod sa
    iyong bahay?) Specify (Sabihin kung saan):____________

    I hereby authorize DepEd -SDO Camarines Sur, 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, Bayaniham to Heal as One Act, to provide truthful
    information.

    _____________________________________
    Signature over Printed Name

    ______________________________
    Date Signed
    ________________________________________________________________________________________________________
    Address: Freedom Sports Complex, San Jose, Pili, Camarines Sur
    Email: [email protected]
    Website: www.depedcamsur.com
    Telephone No: (telefax) 8713340

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