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    Me ATTESTATION FORM TEMPLATE

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    Noel Ephraim Antigua
    The attestation form declares that: 1) all individuals listed work at Butuan Medical Centre and are eligible for the COVID-19 vaccine, 2) all personal information provided by individuals for the vaccine registry was given voluntarily and with knowledge of its use, and 3) the hospital director attests that the information is true and correct to the best of his knowledge. The form was signed on March 5, 2021 in Butuan City, Philippines.

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    Me ATTESTATION FORM TEMPLATE

    Uploaded by

    Noel Ephraim Antigua
    925 views1 page
    The attestation form declares that: 1) all individuals listed work at Butuan Medical Centre and are eligible for the COVID-19 vaccine, 2) all personal information provided by individuals for the vaccine registry was given voluntarily and with knowledge of its use, and 3) the hospital director attests that the information is true and correct to the best of his knowledge. The form was signed on March 5, 2021 in Butuan City, Philippines.

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    The attestation form declares that: 1) all individuals listed work at Butuan Medical Centre and are eligible for the COVID-19 vaccine, 2) all personal information provided by individuals for the vaccine registry was given voluntarily and with knowledge of its use, and 3) the hospital director attests that the information is true and correct to the best of his knowledge. The form was signed on March 5, 2021 in Butuan City, Philippines.

    Copyright:

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

    Me ATTESTATION FORM TEMPLATE

    Uploaded by

    Noel Ephraim Antigua
    The attestation form declares that: 1) all individuals listed work at Butuan Medical Centre and are eligible for the COVID-19 vaccine, 2) all personal information provided by individuals for the vaccine registry was given voluntarily and with knowledge of its use, and 3) the hospital director attests that the information is true and correct to the best of his knowledge. The form was signed on March 5, 2021 in Butuan City, Philippines.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    ATTESTATION FORM

    I, ANDRE C. MALBAS, MD, Assistant Hospital Director, the duly authorized representative of Butuan
    Medical Centre, do hereby declare and attest to the following:

    1. That all individuals listed are part of this facility/institution of the City Government of Butuan,
    Caraga Region; are among the list of the priority population; and are eligible to receive the
    COVID-19 vaccine;

    2. That all individuals listed in the Vaccine Information Management System- Immunization
    Registry (VIMS-IR) have provided the information indicated therein with full knowledge that the
    processing thereof is necessary for the generation of the masterlist for vaccination to the VIMS-
    IR in order to reduce the morbidity and mortality due to COVID-19, in accordance with the
    Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012;

    3. That all individuals listed in the VIMS-IR Form and encoded/uploaded to the VIMS-IR have
    provided the information indicated therein with expectation that the relevant government agencies
    will uphold the rights of the data subjects, implement the appropriate security measures, and will
    remain adherent to the general data privacy principles of transparency, legitimate purpose, and
    proportionality, in processing their personal information; and

    4. That all matters set forth in this VIMS-IR Form or uploaded to the VIMS-IR have been made in
    good faith, duly verified by me and to the best of my knowledge and belief are true and correct.

    Done this ____ day of _______________, 2021 in __________________

    ANDRE C. MALBAS, MD
    Assistant Hospital Director, Butuan Medical Centre

    SUBSCRIBED AND SWORN to before me this 05 March 2021, at Butuan City, Philippines,
    affiant exhibiting his ID _____________________ as competent evidence of his identity.

    Doc. No. ______________;


    Page No. _____________;
    Book No. _____________;
    Series of 2021.

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