This document is a health declaration form used to screen individuals for COVID-19 symptoms and exposure risks. It collects personal information like name, address, temperature and asks a series of yes or no questions. The questions screen for COVID-19 symptoms, contact with confirmed cases, travel history and visiting other areas. By signing, the individual authorizes the establishment to collect and process the data for controlling the COVID-19 infection while protecting their privacy under relevant laws.
This document is a health declaration form used to screen individuals for COVID-19 symptoms and exposure risks. It collects personal information like name, address, temperature and asks a series of yes or no questions. The questions screen for COVID-19 symptoms, contact with confirmed cases, travel history and visiting other areas. By signing, the individual authorizes the establishment to collect and process the data for controlling the COVID-19 infection while protecting their privacy under relevant laws.
This document is a health declaration form used to screen individuals for COVID-19 symptoms and exposure risks. It collects personal information like name, address, temperature and asks a series of yes or no questions. The questions screen for COVID-19 symptoms, contact with confirmed cases, travel history and visiting other areas. By signing, the individual authorizes the establishment to collect and process the data for controlling the COVID-19 infection while protecting their privacy under relevant laws.
This document is a health declaration form used to screen individuals for COVID-19 symptoms and exposure risks. It collects personal information like name, address, temperature and asks a series of yes or no questions. The questions screen for COVID-19 symptoms, contact with confirmed cases, travel history and visiting other areas. By signing, the individual authorizes the establishment to collect and process the data for controlling the COVID-19 infection while protecting their privacy under relevant laws.
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HEALTH DECLARATION FORM HEALTH DECLARATION FORM
Temperature: ____ Temperature: ____
Name: ____________________________________ Sex: ________ Age: ____ Name: ____________________________________ Sex: ________ Age: ____ Address: _____________________________ Contact No: ________________ Address: _____________________________ Contact No: ________________ _____________________________ _____________________________ Nature of Visit: Official ____ If Official, fill-in company details below Nature of Visit: Official ____ If Official, fill-in company details below (Please check one) Personal ___ (Please check one) Personal ___ Company Name: _________________________________________________ Company Name: _________________________________________________ Company Address: _______________________________________________ Company Address: _______________________________________________ 1. Are you YES NO 1. Are you YES NO experiencing: a. Sore experiencing: a. Sore (nakakaranas ka (Pananakit ng lalamunan/masakit (nakakaranas ka (Pananakit ng lalamunan/masakit ba ng:) lumunok) ba ng:) lumunok) b. Body Pains b. Body Pains (pananakit ng katawan) (pananakit ng katawan) c. Headache c. Headache (pananakit ng ulo) (pananakit ng ulo) d. Fever for the past few days d. Fever for the past few days (lagnat sa nakalipas na mga araw) (lagnat sa nakalipas na mga araw) 2. Have you worked together or stayed in the same close 2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? (May nakasama environment of a confirmed COVID-19 case? (May nakasama ka ba or nakatrabahong tao na kumpirmadong may COVID- ka ba or nakatrabahong tao na kumpirmadong may COVID- 19/may impeksyon ng corona virus?) 19/may impeksyon ng corona virus?) 3. Have you had any contact with anyone with fever, cough, 3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka colds, and sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas na dalawang (2) lingo? lalamunan sa nakalipas na dalawang (2) lingo? 4. Have you travelled outside of the Philippines in the past 4. Have you travelled outside of the Philippines in the past 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?) nakalipas na 14 na araw?) 5. Have you travelled to any area in NCR aside from your 5. Have you travelled to any area in NCR aside from your home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong bahay?) Specify o Sabihin kung Metro Manila bukod sa iyong bahay?) Specify o Sabihin kung saan?______________________________________ saan?______________________________________
I hereby authorize [name of establishment] to collect and process the data I hereby authorize [name of establishment] to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by 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, RA 10173 Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heals as One Act, to provide truthful information. Bayanihan to Heals as One Act, to provide truthful information.
Temperature: ____ Temperature: ____ Name: ____________________________________ Sex: ________ Age: ____ Name: ____________________________________ Sex: ________ Age: ____ Address: _____________________________ Contact No: ________________ Address: _____________________________ Contact No: ________________ _____________________________ _____________________________ Nature of Visit: Official ____ If Official, fill-in company details below Nature of Visit: Official ____ If Official, fill-in company details below (Please check one) Personal ___ (Please check one) Personal ___ Company Name: _________________________________________________ Company Name: _________________________________________________ Company Address: _______________________________________________ Company Address: _______________________________________________ 1. Are you YES NO 1. Are you YES NO experiencing: a. Sore experiencing: a. Sore (nakakaranas ka (Pananakit ng lalamunan/masakit (nakakaranas ka (Pananakit ng lalamunan/masakit ba ng:) lumunok) ba ng:) lumunok) b. Body Pains b. Body Pains (pananakit ng katawan) (pananakit ng katawan) c. Headache c. Headache (pananakit ng ulo) (pananakit ng ulo) d. Fever for the past few days d. Fever for the past few days (lagnat sa nakalipas na mga araw) (lagnat sa nakalipas na mga araw) 2. Have you worked together or stayed in the same close 2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? (May nakasama environment of a confirmed COVID-19 case? (May nakasama ka ba or nakatrabahong tao na kumpirmadong may COVID- ka ba or nakatrabahong tao na kumpirmadong may COVID- 19/may impeksyon ng corona virus?) 19/may impeksyon ng corona virus?) 3. Have you had any contact with anyone with fever, cough, 3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks? (Mayroon ka colds, and sore throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas na dalawang (2) lingo? lalamunan sa nakalipas na dalawang (2) lingo? 4. Have you travelled outside of the Philippines in the past 4. Have you travelled outside of the Philippines in the past 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa 14 days? (Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?) nakalipas na 14 na araw?) 5. Have you travelled to any area in NCR aside from your 5. Have you travelled to any area in NCR aside from your home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o home? (Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong bahay?) Specify o Sabihin kung Metro Manila bukod sa iyong bahay?) Specify o Sabihin kung saan?______________________________________ saan?______________________________________
I hereby authorize [name of establishment] to collect and process the data I hereby authorize [name of establishment] to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by 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, RA 10173 Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heals as One Act, to provide truthful information. Bayanihan to Heals as One Act, to provide truthful information.
Thomas J. Fogarty MD, Amitava Biswas MD (Auth.), Thomas J. Fogarty, Rodney A. White (Eds.) - Peripheral Endovascular Interventions-Springer-Verlag New York (2010)
