DEPARTMENT OF EDUCATION
Region I
PANGASINAN DIVISION II
SISON DISTRICT
ASAN SUR ELEMENTARY SCHOOL
School Year 2021 – 2022
HEALTH DECLARTION FORM
Name: _____________________________ Date: _______________ Time: __________ Body Temperature: _________
Age: __________ Contact Number: _________________ Address: __________________________________________
Yes No
a. Sore Throat
(pananakit ng lalamunan/masakit lumunok)
b. Body Pains
1. Are you expereincing (pananakit ng katawan)
(Nakakaranas ka ba ng) c. Fever for the Past Few Days
(lagnat sa nakalipas na araw)
d. Headache
(pananakit ng ulo)
2. Have you worked together or stayed in the same close environment with a confrimed COVID-19 case?
(May nakasama ka ba o nakatarabahong tao na kumpirmadong may COVID-19?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past two weeks? (Mayroon ka
bang nakasalamuha na may lagnat, ubo, sipon, o sakit ng lalamunan sa nakalipas na dalawang lingo?)
4. Have you travelled outside Pangasinan? (Ikaw ba ay nagbyahe sa labas ng Pangasinan?)
5. Have you travelled to any area in Pangasinan aside from your home? (Ikaw ba ay nakabyahe sa ibang parte ng
Pangasinan maliban sa iyong bahay?) Specify (Sabihin kung saan at kailan?)______________________________
Declaration: I hereby certify that the above information is true and complete. I understand that my failure to answer, or any false and
misleading information given by me may be used as ground for the filing of cases against me under Articles 171 & 172 of the Revised
Penal Code of the Philippines or Republic Act No.11332, otherwise as the “Law on Reporting of Communicable Disease”.
__________________________________________
Signature Over Printed Name
DEPARTMENT OF EDUCATION
Region I
PANGASINAN DIVISION II
SISON DISTRICT
ASAN SUR ELEMENTARY SCHOOL
School Year 2021 – 2022
HEALTH DECLARTION FORM
Name: _____________________________ Date: _______________ Time: __________ Body Temperature: _________
Age: __________ Contact Number: _________________ Address: __________________________________________
Yes No
a. Sore Throat
(pananakit ng lalamunan/masakit lumunok)
b. Body Pains
1. Are you expereincing (pananakit ng katawan)
(Nakakaranas ka ba ng) c. Fever for the Past Few Days
(lagnat sa nakalipas na araw)
d. Headache
(pananakit ng ulo)
2. Have you worked together or stayed in the same close environment with a confrimed COVID-19 case?
(May nakasama ka ba o nakatarabahong tao na kumpirmadong may COVID-19?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past two weeks? (Mayroon ka
bang nakasalamuha na may lagnat, ubo, sipon, o sakit ng lalamunan sa nakalipas na dalawang lingo?)
4. Have you travelled outside Pangasinan? (Ikaw ba ay nagbyahe sa labas ng Pangasinan?)
5. Have you travelled to any area in Pangasinan aside from your home? (Ikaw ba ay nakabyahe sa ibang parte ng
Pangasinan maliban sa iyong bahay?) Specify (Sabihin kung saan at kailan?)______________________________
Declaration: I hereby certify that the above information is true and complete. I understand that my failure to answer, or any false and
misleading information given by me may be used as ground for the filing of cases against me under Articles 171 & 172 of the Revised
Penal Code of the Philippines or Republic Act No.11332, otherwise as the “Law on Reporting of Communicable Disease”.
__________________________________________
Signature Over Printed Name
