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Health Declaration Form For DepEd Personnel

The document is a Health Declaration Form from the Department of Education in the Philippines aimed at preventing the spread of COVID-19 among teaching and non-teaching personnel. It requests individuals to provide personal information and self-declare any symptoms, contact with confirmed COVID-19 cases, and recent travel history. The information collected will be used for precautionary measures and handled in accordance with the Privacy Act.

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Palanog Elementary School (R V - Albay)
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88 views1 page

Health Declaration Form For DepEd Personnel

The document is a Health Declaration Form from the Department of Education in the Philippines aimed at preventing the spread of COVID-19 among teaching and non-teaching personnel. It requests individuals to provide personal information and self-declare any symptoms, contact with confirmed COVID-19 cases, and recent travel history. The information collected will be used for precautionary measures and handled in accordance with the Privacy Act.

Uploaded by

Palanog Elementary School (R V - Albay)
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Republic of the Philippines

Department of Education
Region V - Bicol
SCHOOLS DIVISION OFFICE OF ALBAY
CAMALIG NORTH DISTRICT
___________ ELEMENTARY SCHOOL
CAMALIG, ALBAY

HEALTH DECLARATION FORM


Dear Valued Teaching and Non-Teaching Personnel,
To prevent the spread of COVID 19 in our community and reduce
the risk of exposure, we would like to request your cooperation by kindly
accomplishing the health survey form below. Your participation is important to
help in instituting precautionary measures in the workplace. Any information that
you have provided will be handled according to the Privacy Act and will only be
used if contact tracing is necessary. Thank you for your time.

NAME: ADDRESS:

MOBILE NO: TEMPERATURE:


AGE: BP:
GENDER: PR:
RR:

Self-Declaration
1. [ ] No Symptoms [ ] With Symptoms
Please put a check mark if you have any of the symptoms below:
[ ] Fever [ ] Dry cough [ ] Body weakness [ ] Headache [ ] LBM [ ] Runny nose
[ ] Tiredness [ ] Sore Throat [ ] Shortness of Breath [ ] Severe Diarrhea
[ ] Loss of Smell/Taste
2. Have you been in contact with any COVID-19 confirmed positive patient?
[ ] Yes [ ] No
3. Travel history:
Date of Departure: ___________ Arrival Date: _____________
Places visited within the past (2) weeks: _____________________
Signature: __________________ Date: _______________

Noted by: ___________________________________


School Head

Verifier: ____________________________________
Clinic Teacher/SBFP Coordinator

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