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    Student Information Form: Republic of The Philippines Tacloban City

    Uploaded by

    Karen Roldan Rosalejos
    This document is a student information form from Leyte Normal University requesting personal and health details from students to allow entry back onto campus when classes resume. It requests name, contact details, degree program, travel history for the last 3 months, current medical symptoms, exposure to COVID-19 patients, and a declaration that the information is true. Students are asked to submit the form by April 24th via email, messenger or text to facilitate safe return to university.

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

    Student Information Form: Republic of The Philippines Tacloban City

    Uploaded by

    Karen Roldan Rosalejos
    30 views1 page
    This document is a student information form from Leyte Normal University requesting personal and health details from students to allow entry back onto campus when classes resume. It requests name, contact details, degree program, travel history for the last 3 months, current medical symptoms, exposure to COVID-19 patients, and a declaration that the information is true. Students are asked to submit the form by April 24th via email, messenger or text to facilitate safe return to university.

    Original Title

    NOEMI MARIE L. ANGCOS

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    This document is a student information form from Leyte Normal University requesting personal and health details from students to allow entry back onto campus when classes resume. It requests name, contact details, degree program, travel history for the last 3 months, current medical symptoms, exposure to COVID-19 patients, and a declaration that the information is true. Students are asked to submit the form by April 24th via email, messenger or text to facilitate safe return to university.

    Copyright:

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

    Student Information Form: Republic of The Philippines Tacloban City

    Uploaded by

    Karen Roldan Rosalejos
    This document is a student information form from Leyte Normal University requesting personal and health details from students to allow entry back onto campus when classes resume. It requests name, contact details, degree program, travel history for the last 3 months, current medical symptoms, exposure to COVID-19 patients, and a declaration that the information is true. Students are asked to submit the form by April 24th via email, messenger or text to facilitate safe return to university.

    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

    LEYTE NORMAL UNIVERSITY


    Tacloban City

    STUDENT INFORMATION FORM

    Dear Students:

    Relative to the COVID-19 pandemic, please fill out this form as honestly and
    accurately as possible and submit it to Mr. Andrew Siguan on or before April 24, 2020 thru
    email, messenger or text message SO YOU CAN ENTER THE UNIVERSITY UPON RESUMPTION
    OF CLASSES. Thank you very much for your cooperation!

    LNU Administration
    PERSONAL DATA
    Name : ANGCOS, NOEMI MARIE L.
    (Family Name/First Name/Middle Name)
    DEGREE PROGRAM : Bachelor of Physical Education
    Year Level :I
    Section : EP1-2
    Student Number : 1904577
    Mobile Number : 09653365586
    Email Address : N/A
    Facebook Name : Noemi Marie Lacambra Angcos
    Father’s Name : Noel Timplado Angcos
    Mother’s Name : Marilyn Amago Lacambra

    Contact Number of Parent/Guardian: 09753885932


    Complete Home Address: Brgy. Caticuggan Sta. Rita Samar

    TRAVEL HISTORY BOTH LOCAL AND INTERNATIONAL FOR THE LAST 3 MONTHS
    (start from the most recent and feel free to add space if necessary)

    Name of place visited: NA


    Travel period: NA

    Name of place visited: NA


    Travel period: NA

    Name of place visited: NA


    Travel period: NA

    MEDICAL HISTORY
    Are you experiencing or suffering from any of the following within the last 14 days?
    Cough (yes/no)
    Fever (yes/no)
    Difficulty in breathing (yes/no)
    Diarrhea (yes/no)
    Colds (yes/no)
    Others: Please Specify: _________________________________________________

    EXPOSURE TO OR CONTACT WITH THE FOLLOWING PERSONS:


    COVID-19 Suspect (Yes/No), Probable (Yes/No), Confirmed (Yes/No)

    CONSIDERED as COVID-19 Suspect (Yes/No), Probable (Yes/No), Confirmed (Yes/No)


    Other Details: ______________________________________________________________________
    ------------------------------------------------------------------------------------------------------------------------------------------
    In my honor, I hereby declare that the above information are true and correct and I am fully
    aware that these will be used by the LNU administration relative to their preparation for the resumption
    of classes.
    SO HELP US GOD!!!
    ANGCOS, NOEMI MARIE L.
    Signature over Printed Name of Student

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