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    Health Declaration Form A1 Whole Page

    Uploaded by

    Fedelyn Semeniano
    This health declaration document collects information from an individual to assess potential COVID-19 infection risks. It asks whether the person is experiencing common COVID-19 symptoms, has been in contact with confirmed COVID-19 cases, lives with someone awaiting test results or showing symptoms, and has recently traveled internationally. The individual declares the information is true and correct and authorizes the collection of their personal data for controlling the spread of COVID-19 infection in accordance with relevant privacy and health laws.

    Copyright:

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

    Health Declaration Form A1 Whole Page

    Uploaded by

    Fedelyn Semeniano
    74 views1 page
    This health declaration document collects information from an individual to assess potential COVID-19 infection risks. It asks whether the person is experiencing common COVID-19 symptoms, has been in contact with confirmed COVID-19 cases, lives with someone awaiting test results or showing symptoms, and has recently traveled internationally. The individual declares the information is true and correct and authorizes the collection of their personal data for controlling the spread of COVID-19 infection in accordance with relevant privacy and health laws.

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    Health Declaration Form a1 Whole Page

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    This health declaration document collects information from an individual to assess potential COVID-19 infection risks. It asks whether the person is experiencing common COVID-19 symptoms, has been in contact with confirmed COVID-19 cases, lives with someone awaiting test results or showing symptoms, and has recently traveled internationally. The individual declares the information is true and correct and authorizes the collection of their personal data for controlling the spread of COVID-19 infection in accordance with relevant privacy and health laws.

    Copyright:

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

    Health Declaration Form A1 Whole Page

    Uploaded by

    Fedelyn Semeniano
    This health declaration document collects information from an individual to assess potential COVID-19 infection risks. It asks whether the person is experiencing common COVID-19 symptoms, has been in contact with confirmed COVID-19 cases, lives with someone awaiting test results or showing symptoms, and has recently traveled internationally. The individual declares the information is true and correct and authorizes the collection of their personal data for controlling the spread of COVID-19 infection in accordance with relevant privacy and health laws.

    Copyright:

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

    HEALTH DECLARATION

    Body Temperature:

    Date: ________________________

    Name: _______________________________________________________ Sex: _______ Age: _______

    Residence: ________________________________________________________________________________

    Contact Number/s: __________________________________________________________________________

    YES NO
    Symptoms (Mga sintomas)
    (Oo) (Hindi)
    a. Sore throat (Pananakit ng lalamunan/masakit lumunok)
    1. Are you experiencing b. Shortness of Breath (Hirap sa paghinga)
    currently or within the
    c. Body pains (Pananakit ng katawan)
    last 14 days:
    d. Headache (Pananakit ng ulo)
    (Nakakaranas ka ba sa
    kasalukuyan o sa huling e. Fever for the past few days (Lagnat sa mga nakalipas na araw)
    14 na araw) f. Loss of taste or smell (Pagkawala ng panlasa o pang-amoy)
    g. Cough and/or cold (Ubo at/o sipon)
    h. Diarrhea (Pagtatae)

    2. Have you worked together or stayed in the same household/ close environment with a
    confirmed COVID-19 case?
    (May nakasama ka ba or nakatrabahong tao na kumpimadong COVID-19 case/may impeksyon ng
    COVID-19?)

    3. Are you living with a household member who is currently waiting for results of his/her
    swab test/ COVID-19 test?
    (Ikaw ba ay may kasama sa bahay na nag-aantay ng resulta ng swab test/ COVID-19 test?)

    4. Have you had any contact with anyone or living with household member with fever,
    cough, colds, sore throat, loss of taste or smell in the past 2 weeks?
    (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng
    dalawang (2) linggo?)

    5. 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?)

    I declare under oath that I personally accomplished this Health Declaration form. Further, I declare that the
    information given are true, correct, and complete statements pursuant to the provisions of pertinent laws, rules,
    and regulations of the Republic of the Philippines.

    I hereby authorize the CIVIL SERVICE COMMISSION (CSC), 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, as
    amended by RA 11494, to provide truthful information. Further, I understand that any false information may have
    serious public health implications and may be subjected to legal consequences. Finally, I understand that, in case I
    would test positive for COVID-19 within 14 days after the exam day, the CSC shall, upon request of the
    LGU/Barangay concerned, provide my necessary/pertinent information for contact tracing.

    Signature: __________________________________

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