Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

Region II – Cagayan Valley Region II – Cagayan Valley
Schools Division of Cagayan Schools Division of Cagayan
Piat National High School Piat National High School
Piat, Cagayan Piat, Cagayan
COVID HEALTH DECLARATION FORM COVID HEALTH DECLARATION FORM
 Name:__________________________________________ Age:____________  Name:__________________________________________ Age:____________
 Contact No. ___________________________________ Sex:______________  Contact No. ___________________________________ Sex:______________
 Complete Address: ________________________________
 Complete Address:________________________________  Foreign Countries or other Regions that you have visited in the last 14 days: ______________________
 Foreign Countries or other Regions that you have visited in the last 14 days: ______________________  Other Municipalities in the Province that you have visited in the last 14 days: ______________________
 Other Municipalities in the Province that you have visited in the last 14 days: ______________________  Have you been sick of any of the following in the last 14 days:
 Have you been sick of any of the following in the last 14 days: Yes No Yes No
Yes No Yes No
Fever Sore Throat
Fever Sore Throat
Cough Difficultly of Breathing
Cough Difficultly of Breathing
Colds Diarrhea
Colds Diarrhea
Headache Loss of sense of Smell
Headache Loss of sense of Smell
Body Pains Loss of sense of Taste
Body Pains Loss of sense of Taste
Disclaimer: All data collected using this form shall only be used in Piat National High School as a precautionary measure for the
Disclaimer: All data collected using this form shall only be used in Piat National High School as a precautionary measure for the protection of all learners. By submitting this form, you agree to share your personal information to the school for this purpose. Thank you.
protection of all learners. By submitting this form, you agree to share your personal information to the school for this purpose. Thank you. _________________________________________
____________________________________________ Signature over printed name:
Signature over printed name:
_________________________________________
____________________________________________ Attested by:
Attested by: Date:
Date:

Republic of the Philippines Republic of the Philippines

Department of Education Department of Education
Region II – Cagayan Valley Region II – Cagayan Valley
Schools Division of Cagayan Schools Division of Cagayan
Piat National High School Piat National High School
Piat, Cagayan Piat, Cagayan
COVID HEALTH DECLARATION FORM
 Name:__________________________________________ Age:____________ COVID HEALTH DECLARATION FORM
 Contact No. ___________________________________ Sex:______________  Name:__________________________________________ Age:____________
 Complete Address:________________________________  Contact No. ___________________________________ Sex:______________
 Complete Address: ________________________________
 Foreign Countries or other Regions that you have visited in the last 14 days: ______________________
 Foreign Countries or other Regions that you have visited in the last 14 days: ______________________
 Other Municipalities in the Province that you have visited in the last 14 days: ______________________  Other Municipalities in the Province that you have visited in the last 14 days: ______________________
 Have you been sick of any of the following in the last 14 days:  Have you been sick of any of the following in the last 14 days:
Yes No Yes No Yes No Yes No

Fever Sore Throat Fever Sore Throat

Cough Difficultly of Breathing Cough Difficultly of Breathing

Colds Diarrhea Colds Diarrhea

Headache Loss of sense of Smell Headache Loss of sense of Smell

Body Pains Loss of sense of Taste Body Pains Loss of sense of Taste

Disclaimer: All data collected using this form shall only be used in Piat National High School as a precautionary measure for the Disclaimer: All data collected using this form shall only be used in Piat National High School as a precautionary measure for the
protection of all learners. By submitting this form, you agree to share your personal information to the school for this purpose. Thank you. protection of all learners. By submitting this form, you agree to share your personal information to the school for this purpose. Thank you.
____________________________________________ __________________________________________
Signature over printed name: Signature over printed name:

____________________________________________ _________________________________________
Attested by: Attested by:
Date: Date:
 Republic of the Philippines
Department of Education
Region II – Cagayan Valley
Schools Division of Cagayan
Piat National High School
Piat, Cagayan
COVID HEALTH DECLARATION FORM
 Name:__________________________________________ Age:____________
 Contact No. ___________________________________ Sex:______________
 Complete Address:________________________________
 Foreign Countries or other Regions that you have visited in the last 14 days: ______________________
 Other Municipalities in the Province that you have visited in the last 14 days: ______________________
 Have you been sick of any of the following in the last 14 days:
Yes No Yes No

Fever Sore Throat

Cough Difficultly of Breathing

Colds Diarrhea

Headache Loss of sense of Smell

Body Pains Loss of sense of Taste

Disclaimer: All data collected using this form shall only be used in Piat National HighSchool as a precautionary measure for the protection
of all learners. By submitting this form, you agree to share your personal information to the school for this purpose. Thank you.

____________________________________________
Signature over printed name:

____________________________________________
Attested by:
Date:
 Republic of the Philippines
Department of Education
Region II – Cagayan Valley
Schools Division of Cagayan
Piat National High School
Piat, Cagayan
COVID HEALTH DECLARATION FORM
 Name:__________________________________________ Age:____________
 Contact No. ___________________________________ Sex:______________
 Complete Address:________________________________
 Foreign Countries or other Regions that you have visited in the last 14 days: ______________________
 Other Municipalities in the Province that you have visited in the last 14 days: ______________________
 Have you been sick of any of the following in the last 14 days:
Yes No Yes No

Fever Sore Throat

Cough Difficultly of Breathing

Colds Diarrhea

Headache Loss of sense of Smell

Body Pains Loss of sense of Taste

Disclaimer: All data collected using this form shall only be used in Piat National HighSchool as a precautionary measure for the protection
of all learners. By submitting this form, you agree to share your personal information to the school for this purpose. Thank you.

____________________________________________
Signature over printed name:

____________________________________________
Attested by:
Date: