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    Health Declaration Form-1-1

    Uploaded by

    Jimmy Lagura
    This document is a health declaration form used by Laoag Central Elementary School in Laoag City. It collects a student's name, grade, temperature, and answers to questions about recent COVID-19 symptoms and potential exposure. It also asks if the student has been vaccinated against COVID-19. The student or guardian must sign the completed form.

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

    Health Declaration Form-1-1

    Uploaded by

    Jimmy Lagura
    18 views2 pages
    This document is a health declaration form used by Laoag Central Elementary School in Laoag City. It collects a student's name, grade, temperature, and answers to questions about recent COVID-19 symptoms and potential exposure. It also asks if the student has been vaccinated against COVID-19. The student or guardian must sign the completed form.

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    health.declaration.form-1-1

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    This document is a health declaration form used by Laoag Central Elementary School in Laoag City. It collects a student's name, grade, temperature, and answers to questions about recent COVID-19 symptoms and potential exposure. It also asks if the student has been vaccinated against COVID-19. The student or guardian must sign the completed form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    18 views2 pages

    Health Declaration Form-1-1

    Uploaded by

    Jimmy Lagura
    This document is a health declaration form used by Laoag Central Elementary School in Laoag City. It collects a student's name, grade, temperature, and answers to questions about recent COVID-19 symptoms and potential exposure. It also asks if the student has been vaccinated against COVID-19. The student or guardian must sign the completed form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    LAOAG CENTRAL ELEMENTARY SCHOOL LAOAG CENTRAL ELEMENTARY SCHOOL LAOAG CENTRAL ELEMENTARY SCHOOL

    Laoag City Laoag City Laoag City

    HEALTH DECLARATION FORM HEALTH DECLARATION FORM HEALTH DECLARATION FORM

    Date: ________________ Date: ________________ Date: ________________


    Name: _______________________________ Name: _______________________________ Name: _______________________________
    Grade & Section: ___________________ Grade & Section: ___________________ Grade & Section: ___________________
    Temperature: ______________________ Temperature: ______________________ Temperature: ______________________

    Direction: Please tick on Yes (or no otherwise) if Direction: Please tick on Yes (or no otherwise) if Direction: Please tick on Yes (or no otherwise) if
    you have recently experienced the following: you have recently experienced the following: you have recently experienced the following:
    Yes No Yes No Yes No
    Sore Throat Sore Throat Sore Throat
    Body Pains Body Pains Body Pains
    Headache Headache Headache
    Fever Fever Fever
    Loss of taste or smell Loss of taste or smell Loss of taste or smell
    Difficulty of breathing Difficulty of breathing Difficulty of breathing

    Have you been in contact or stayed in the Have you been in contact or stayed in the Have you been in contact or stayed in the
    same close environment of the confirmed COVID- same close environment of the confirmed COVID- same close environment of the confirmed COVID-
    19 case within the week? YES NO 19 case within the week? YES NO 19 case within the week? YES NO

    Have you been vaccinated against COVID- Have you been vaccinated against COVID- Have you been vaccinated against COVID-
    19? (Personnel on duty may require you to show 19? (Personnel on duty may require you to show 19? (Personnel on duty may require you to show
    you your vaccination card.) you your vaccination card.) you your vaccination card.)
    Yes No Yes No Yes No
    First dose: First dose: First dose:
    Second dose Second dose Second dose
    Additional dose: Additional dose: Additional dose:

    _________________________________ _________________________________ _________________________________


    Signature Signature Signature

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