HEALTH DECLARATION TEMPERATURE: _______________ HEALTH DECLARATION TEMPERATURE: _______________
FULL Name : Date : : FULL Name : Date : :
(Buong Pangalan) (Petsa) (MM/DD/YY) (Buong Pangalan) (Petsa) (MM/DD/YY)
Complete Current Address) : Complete Current Address) :
(Kasalukuyang tirahan (Kasalukuyang tirahan
Mobile/Phone Number : Time: Mobile/Phone Number : Time:
(Numero ng telepono) (Numero ng telepono)
Email Address : Email Address :
Put a Check mark on the appropriate column of your response. Put a Check mark on the appropriate column of your response.
(Lagyan ng tsek sa angkop na sagot.) (Lagyan ng tsek sa angkop na sagot.)
Yes No Yes No
(Oo) (Hindi) (Oo) (Hindi)
a. Fever (Lagnat) a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon) b. Cough and/or Colds (Ubo at/o Sipon)
c. Body pains (Pananakit ng katawan) c. Body pains (Pananakit ng katawan)
1. Are you experiencing or did you have any of d. Sore Throat (Pananakit ng laamunan) 1. Are you experiencing or did you have any of d. Sore Throat (Pananakit ng laamunan)
the following in the last 14 days? (Ikaw ba ay e. Fatique/Tiredness (Pagkapagod) the following in the last 14 days? (Ikaw ba ay e. Fatique/Tiredness (Pagkapagod)
may nararanasan o nakararanas ng mga f. Headache (Pananakit ng ulo) may nararanasan o nakararanas ng mga f. Headache (Pananakit ng ulo)
sumusunod na sintomas sa nakaraang 14 na sumusunod na sintomas sa nakaraang 14 na
g. Diarrhea (Pagtatae) g. Diarrhea (Pagtatae)
araw araw
h. Loss of taste/smell (Nawalan ng h. Loss of taste/smell (Nawalan ng
panglasa at pang-amoy) panglasa at pang-amoy)
i. Difficulty of breathing (Pagkahapo o i. Difficulty of breathing (Pagkahapo o
hirap sa paghinga) hirap sa paghinga)
2. Have you had face-to-face contact with a 2. Have you had face-to-face contact with a
probable or confirmed COVID-19 case within 1 probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the meter and for more than 15 minutes for the
past 14 days? (May nakasalamuha kaba na past 14 days? (May nakasalamuha kaba na
maaaring o kumpirmadong pasyente na may maaaring o kumpirmadong pasyente na may
COVID-19 mula sa isang metrong distansiya o COVID-19 mula sa isang metrong distansiya o
mas malapit pa at tumagal ng mahigit 15 mas malapit pa at tumagal ng mahigit 15
minuto sa nakalipas na 14 na araw?) minuto sa nakalipas na 14 na araw?)
3. Have you provided direct care for a patient 3. Have you provided direct care for a patient
with probable or confirmed COVID-19 wthout with probable or confirmed COVID-19 wthout
using proper “Personal Protective Eqipment using proper “Personal Protective Eqipment
(PPE)” for the past 14 days? (Nag-alaga kaba (PPE)” for the past 14 days? (Nag-alaga kaba
ng maaaring o kumpirmadong pasyente na ng maaaring o kumpirmadong pasyente na
may COVID-19 ng hindi nakasuot ng tamang may COVID-19 ng hindi nakasuot ng tamang
PPE (Personal Protective Equipment sa PPE (Personal Protective Equipment sa
nakalipas ng 14 na araw? nakalipas ng 14 na araw?
4. Have you travelled outside the Philippines 4. Have you travelled outside the Philippines
in the last 14 days? (Ikaw ba ay nagbiyahe sa in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas ng 14 na araw?) labas ng Pilipinas sa nakalipas ng 14 na araw?)
5. Have you travelled outside the current 5. Have you travelled outside the current
city/municipality where you reside? (Ikaw ba city/municipality where you reside? (Ikaw ba
kaw ba ay nagbiyahe sa labas ng inyong kaw ba ay nagbiyahe sa labas ng inyong
lungsod /munisipyo?) If yes, specify which lungsod /munisipyo?) If yes, specify which
city/municipality you went to (Sabihin kung city/municipality you went to (Sabihin kung
saan) : saan) :
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
questions or any falsified response may have serious consequences. I understand that my personal information is questions 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 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. of accomplishment, following the National Archives of the Philippines protocol.
Signature (Lagda) : Signature (Lagda) :
HEALTH DECLARATION TEMPERATURE: __________
HEALTH DECLARATION TEMPERATURE: __________
FULL Name : Date : :
FULL Name : Date : :
(Buong Pangalan) (Petsa) (MM/DD/YY)
(Buong Pangalan) (Petsa) (MM/DD/YY)
Complete Current Address) :
Complete Current Address) :
(Kasalukuyang tirahan
(Kasalukuyang tirahan
Mobile/Phone Number : Time:
Mobile/Phone Number : Time:
(Numero ng telepono)
(Numero ng telepono)
Email Address :
Email Address :
Put a Check mark on the appropriate column of your response.
Put a Check mark on the appropriate column of your response.
(Lagyan ng tsek sa angkop na sagot.)
(Lagyan ng tsek sa angkop na sagot.)
Yes No
Yes No
(Oo) (Hindi)
(Oo) (Hindi)
a. Fever (Lagnat)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
b. Cough and/or Colds (Ubo at/o Sipon)
c. Body pains (Pananakit ng katawan)
c. Body pains (Pananakit ng katawan) 1. Are you experiencing or did you have any of
1. Are you experiencing or did you have any of d. Sore Throat (Pananakit ng laamunan)
d. Sore Throat (Pananakit ng laamunan) the following in the last 14 days? (Ikaw ba ay
the following in the last 14 days? (Ikaw ba ay e. Fatique/Tiredness (Pagkapagod)
e. Fatique/Tiredness (Pagkapagod) may nararanasan o nakararanas ng mga
may nararanasan o nakararanas ng mga f. Headache (Pananakit ng ulo)
f. Headache (Pananakit ng ulo) sumusunod na sintomas sa nakaraang 14 na
sumusunod na sintomas sa nakaraang 14 na g. Diarrhea (Pagtatae)
g. Diarrhea (Pagtatae) araw
araw h. Loss of taste/smell (Nawalan ng
h. Loss of taste/smell (Nawalan ng
panglasa at pang-amoy)
panglasa at pang-amoy)
i. Difficulty of breathing (Pagkahapo o
i. Difficulty of breathing (Pagkahapo o
hirap sa paghinga)
hirap sa paghinga)
2. Have you had face-to-face contact with a
2. Have you had face-to-face contact with a
probable or confirmed COVID-19 case within 1
probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the
meter and for more than 15 minutes for the
past 14 days? (May nakasalamuha kaba na
past 14 days? (May nakasalamuha kaba na
maaaring o kumpirmadong pasyente na may
maaaring o kumpirmadong pasyente na may
COVID-19 mula sa isang metrong distansiya o
COVID-19 mula sa isang metrong distansiya o
mas malapit pa at tumagal ng mahigit 15
mas malapit pa at tumagal ng mahigit 15
minuto sa nakalipas na 14 na araw?)
minuto sa nakalipas na 14 na araw?)
3. Have you provided direct care for a patient
3. Have you provided direct care for a patient
with probable or confirmed COVID-19 wthout
with probable or confirmed COVID-19 wthout
using proper “Personal Protective Eqipment
using proper “Personal Protective Eqipment
(PPE)” for the past 14 days? (Nag-alaga kaba
(PPE)” for the past 14 days? (Nag-alaga kaba
ng maaaring o kumpirmadong pasyente na
ng maaaring o kumpirmadong pasyente na
may COVID-19 ng hindi nakasuot ng tamang
may COVID-19 ng hindi nakasuot ng tamang
PPE (Personal Protective Equipment sa
PPE (Personal Protective Equipment sa
nakalipas ng 14 na araw?
nakalipas ng 14 na araw?
4. Have you travelled outside the Philippines
4. Have you travelled outside the Philippines
in the last 14 days? (Ikaw ba ay nagbiyahe sa
in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas ng 14 na araw?)
labas ng Pilipinas sa nakalipas ng 14 na araw?)
5. Have you travelled outside the current
5. Have you travelled outside the current
city/municipality where you reside? (Ikaw ba
city/municipality where you reside? (Ikaw ba
kaw ba ay nagbiyahe sa labas ng inyong
kaw ba ay nagbiyahe sa labas ng inyong
lungsod /munisipyo?) If yes, specify which
lungsod /munisipyo?) If yes, specify which
city/municipality you went to (Sabihin kung
city/municipality you went to (Sabihin kung
saan) :
saan) :
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
questions or any falsified response may have serious consequences. I understand that my personal information is
questions 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
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.
of accomplishment, following the National Archives of the Philippines protocol.
Signature (Lagda) :
Signature (Lagda) :
