Date: ____________ Logbook No.
: _________ Temperature: _________°C Signature Date
Name Name
Age/Sex School Teniapan NHS Age/Sex School Teniapan NHS
Employee ID Employee ID
District: San Pablo 1 District: San Pablo 1
No. No.
Office to Office to
Transact Transact
Purpose Purpose
DECLARATION DECLARATION
I am free of COVID-19 symptoms (or have confirmed my symptoms I am free of COVID-19 symptoms (or have confirmed my symptoms
are not COVID-19 related) including the following: are not COVID-19 related) including the following:
- Loss of sense of smell or taste - Sore throat - Loss of sense of smell or taste - Sore throat
- Fever - Colds/Runny nose - Fever - Colds/Runny nose
- Cough - Shortness of breath - Cough - Shortness of breath
I have not been in contact with a Suspect, Probable or Confirmed I have not been in contact with a Suspect, Probable or Confirmed
case of COVID-19 in the last 14 days. case of COVID-19 in the last 14 days.
I am not currently directed to isolate or quarantine. I am not currently directed to isolate or quarantine.
I have not travelled to high-risk areas outside of the province
province. I have not travelled to high-risk areas outside of the province.
Declaration and Data Privacy Consent Form: Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.
I certify that the above information given is true, correct and complete. I Date: ____________ Logbook No.: _________ Temperature: _________°C
acknowledge and understand that giving false information is punishable by law.
Declaration and Data Privacy Consent Form:
I voluntarily and freely consent to the collection and sharing of the above personal
information only in relation to the DepEd-Zamboanga del Sur COVID-19 I certify that the above information given is true, correct and complete. I
protocols. acknowledge and understand that giving false information is punishable by law.
I voluntarily and freely consent to the collection and sharing of the above personal
__________________________ _____________ information only in relation to the DepEd-Zamboanga del Sur COVID-19
Signature Date protocols.
Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act. __________________________ _____________
Signature Date
Please be advised that the above information shall only be used in relation to
Name Name
Age/Sex School Teniapan NHS Age/Sex School Teniapan NHS
Employee ID Employee ID
District: San Pablo 1 District: San Pablo 1
No. No.
Office to Office to
Transact Transact
Purpose Purpose
DECLARATION DECLARATION
I am free of COVID-19 symptoms (or have confirmed my symptoms I am free of COVID-19 symptoms (or have confirmed my symptoms
are not COVID-19 related) including the following: are not COVID-19 related) including the following:
- Loss of sense of smell or taste - Sore throat - Loss of sense of smell or taste - Sore throat
- Fever - Colds/Runny nose - Fever - Colds/Runny nose
- Cough - Shortness of breath - Cough - Shortness of breath
I have not been in contact with a Suspect, Probable or Confirmed I have not been in contact with a Suspect, Probable or Confirmed
case of COVID-19 in the last 14 days. case of COVID-19 in the last 14 days.
I am not currently directed to isolate or quarantine. I am not currently directed to isolate or quarantine.
I have not travelled to high-risk areas outside of the province. I have not travelled to high-risk areas outside of the province.
Date: ____________ Logbook No.: _________ Temperature: _________°C DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.
Declaration and Data Privacy Consent Form:
I certify that the above information given is true, correct and complete. I Date: ____________ Logbook No.: _________ Temperature: _________°C
acknowledge and understand that giving false information is punishable by law.
I voluntarily and freely consent to the collection and sharing of the above personal Declaration and Data Privacy Consent Form:
information only in relation to the DepEd-Zamboanga del Sur COVID-19 I certify that the above information given is true, correct and complete. I
protocols. acknowledge and understand that giving false information is punishable by law.
__________________________ _____________
I voluntarily and freely consent to the collection and sharing of the above personal
information only in relation to the DepEd-Zamboanga del Sur COVID-19
protocols.
__________________________ _____________
Signature Date
Please be advised that the above information shall only be used in relation to
DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.
