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    Health Declaration Form For Visitors

    Uploaded by

    ANGELYN AUSTRIA
    The form collects personal information and health status from individuals, asking questions about symptoms experienced in the last 14 days, contact with COVID-19 patients, travel history, and certifying the information is true; it is intended to screen for COVID-19 risks and protects personal data under Philippine privacy laws.

    Copyright:

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

    Health Declaration Form For Visitors

    Uploaded by

    ANGELYN AUSTRIA
    29 views1 page
    The form collects personal information and health status from individuals, asking questions about symptoms experienced in the last 14 days, contact with COVID-19 patients, travel history, and certifying the information is true; it is intended to screen for COVID-19 risks and protects personal data under Philippine privacy laws.

    Original Title

    Health-Declaration-Form-for-Visitors

    Copyright

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    The form collects personal information and health status from individuals, asking questions about symptoms experienced in the last 14 days, contact with COVID-19 patients, travel history, and certifying the information is true; it is intended to screen for COVID-19 risks and protects personal data under Philippine privacy laws.

    Copyright:

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

    Health Declaration Form For Visitors

    Uploaded by

    ANGELYN AUSTRIA
    The form collects personal information and health status from individuals, asking questions about symptoms experienced in the last 14 days, contact with COVID-19 patients, travel history, and certifying the information is true; it is intended to screen for COVID-19 risks and protects personal data under Philippine privacy laws.

    Copyright:

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

    COMMISSION
    ON ELECTIONS
    HEALTH DECLARATION FORM
    Full Name (Buong Pangalan) Date {Petsa) (MM/DD/VY):
    Time {Oras)
    Complete Current Address (Kasa/ukuyang tirahan):

    Mobile/Phone Number {Numero ng telepono)


    Email Address:
    Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)
    Yes (Oo} No (Hindi)
    a. Fever (Lagnat)
    1. Are you experiencing or b. Cough and/or Colds (Ubo at/o Sipon)
    did you have any of the c. Body pains (Pananakit ng katawan)
    following in the last 14
    d. Sore Throat (Pananakit o pamamaga ng /alamunan)
    days? {lkaw ba ay may
    e. Fatigue/Tiredness (Pagkapagod)
    nararanasan o nakaranas
    f. Headache (Pananakit ng ulo)
    ng mga sumusunod na
    g. Diarrhea (Pagtatae)
    sintomas sa nakaraang 14
    na araw?) h. Loss of taste or smell (Nawalan ng panlasa o pang-amoy)
    i. Difficulty of breathing (Pagkahapo o hirap sa pag hinga)
    2. Have you had face-to-face contact with a probable or confirmed COVID-19 case
    within 1 meter and for more than 15 minutes for the past 14 days? (May
    nakasalamuha ka ba na maaaring o kumpirmadong pasyente na may COV/D-19 mu/a
    sa isang metrong distansya or mas malapit pa at tumagal ng mahigit 15 minuto sa
    nakalipas na 14 araw?)

    3. Have you provided direct care for a patient with probable or confirmed COVID-19
    case without using proper "Personal Protective Equipment (PPE)" for the past 14 days?
    (Nag- a/aga ka ba ng maaring o kumpirmadong pasyente na may COV/D-19 ng hindi
    nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?)

    4. Have you traveled outside the Philippines in the last 14 days? {lkaw ba ay
    nagbiyahe
    sa labas ng Pilipinas sa nakalipas na 14 na araw?)
    5. Have you traveled outside the current city/municipality where you reside? {lkaw ba
    ay nagbiyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify which
    city/municipality you went to (Sabihin kung saan)

    I hereby certify that the information given is true, correct and complete. I understand that
    failure to answer any question or any falsified response may have serious consequences. I
    understand that my personal information is protected by RA 10173 or the Data Privacy Act of 2012
    and that this form will be destroyed after 20 days from the date of accomplishment, following the
    National Archives of the Philippines protocol.

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