HEALTH DECLARATION FORM Temp:_________ HEALTH DECLARATION FORM Temp:_________

Name:_____________________________________________________________ Name:_____________________________________________________________
Sex:_______ Age:________ Sex:_______ Age:________
Residence:_________________________________________________________ Residence:_________________________________________________________
(If official visit): (If official visit):
Company Name:_____________________________________________________ Company Name:_____________________________________________________

1. Are you YES NO 1. Are you YES NO

experiencing: m. Sore throat (pananakit ng experiencing: a. Sore throat (pananakit ng
(nakakaranas lalamunan/masakit (nakakaranas lalamunan/masakit
ka ba ng: ) lumunok) ka ba ng: ) lumunok)
n. Body pains (pananakit ng b. Body pains (pananakit ng
katawan) katawan)
o. Headache (pananakit ng c. Headache (pananakit ng
ulo) ulo)
p. Fever for the past few d. Fever for the past few
days (lagnat sa nakalipas days (lagnat sa nakalipas
na mga araw) na mga araw)
2. Have you worked together or stayed in the same close 2. Have you worked together or stayed in the same close
environment of a confirmed COVID-19 case? (May environment of a confirmed COVID-19 case? (May
nakasama ka ba o nakatrabahong tao na nakasama ka ba o nakatrabahong tao na
kumpirmadong may COVID-19/ may impeksyon ng kumpirmadong may COVID-19/ may impeksyon ng
coronavirus?) coronavirus?)
3. Have you had any contact with anyone with fever, 3. Have you had any contact with anyone with fever,
cough, colds, and sore throat in the past 2 weeks? cough, colds, and sore throat in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, (Mayroon ka bang nakasama na may lagnat, ubo,
sipon o sakit ng lalamunan sa nakalipas na (2) lingo?) sipon o sakit ng lalamunan sa nakalipas na (2) lingo?)
4. Have you travelled outside of the Philippines in the last 4. Have you travelled outside of the Philippines in the last
14 days? (ikaw ba ay nagbyahe sa labas ng Pilipinas 14 days? (ikaw ba ay nagbyahe sa labas ng Pilipinas
sa nakalipas na 14 na araw?) sa nakalipas na 14 na araw?)
5. Have you travelled to any area in NCR aside from your 5. Have you travelled to any area in NCR aside from your
home? (ikaw ba ay nagpunta sa iba pang parte ng home? (ikaw ba ay nagpunta sa iba pang parte ng
NCR o Metro Manila bukod sa iyong bahay?) Specify NCR o Metro Manila bukod sa iyong bahay?) Specify
(Sabihin kung saan) (Sabihin kung saan)
:____________________________ :____________________________
I hereby authorize UCV to collect and process the data indicated herein for the I hereby authorize UCV to collect and process the data indicated herein for the
purpose of effecting control of the COVID-19 infection. I understand that my personal purpose of effecting control of the COVID-19 infection. I understand that my personal
information is protected by RA 10173, Data Privacy Act of 2012, and that I am information is protected by RA 10173, Data Privacy Act of 2012, and that I am
required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature:_________________________ Date:__________________ Signature:_________________________ Date:__________________

HEALTH DECLARATION FORM Temp:_________ HEALTH DECLARATION FORM Temp:_________

Name:_____________________________________________________________ Name:_____________________________________________________________
Sex:_______ Age:________ Sex:_______ Age:________
Residence:_________________________________________________________ Residence:_________________________________________________________
(If official visit): (If official visit):
Company Name:_____________________________________________________ Company Name:_____________________________________________________

1. Are you YES NO 1. Are you YES NO

experiencing: i. Sore throat (pananakit ng experiencing: e. Sore throat (pananakit ng
(nakakaranas lalamunan/masakit (nakakaranas lalamunan/masakit
ka ba ng: ) lumunok) ka ba ng: ) lumunok)
j. Body pains (pananakit ng f. Body pains (pananakit ng
katawan) katawan)
k. Headache (pananakit ng g. Headache (pananakit ng
ulo) ulo)
l. Fever for the past few h. Fever for the past few
days (lagnat sa nakalipas days (lagnat sa nakalipas
na mga araw) na mga araw)
2. Have you worked together or stayed in the same close 2. Have you worked together or stayed in the same close
environment of a confirmed COVID-19 case? (May environment of a confirmed COVID-19 case? (May
nakasama ka ba o nakatrabahong tao na nakasama ka ba o nakatrabahong tao na
kumpirmadong may COVID-19/ may impeksyon ng kumpirmadong may COVID-19/ may impeksyon ng
coronavirus?) coronavirus?)
3. Have you had any contact with anyone with fever, 3. Have you had any contact with anyone with fever,
cough, colds, and sore throat in the past 2 weeks? cough, colds, and sore throat in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, (Mayroon ka bang nakasama na may lagnat, ubo,
sipon o sakit ng lalamunan sa nakalipas na (2) lingo?) sipon o sakit ng lalamunan sa nakalipas na (2) lingo?)
4. Have you travelled outside of the Philippines in the last 4. Have you travelled outside of the Philippines in the last
14 days? (ikaw ba ay nagbyahe sa labas ng Pilipinas 14 days? (ikaw ba ay nagbyahe sa labas ng Pilipinas
sa nakalipas na 14 na araw?) sa nakalipas na 14 na araw?)
5. Have you travelled to any area in NCR aside from your 5. Have you travelled to any area in NCR aside from your
home? (ikaw ba ay nagpunta sa iba pang parte ng home? (ikaw ba ay nagpunta sa iba pang parte ng
NCR o Metro Manila bukod sa iyong bahay?) Specify NCR o Metro Manila bukod sa iyong bahay?) Specify
(Sabihin kung saan) (Sabihin kung saan)
:____________________________ :____________________________
I hereby authorize UCV to collect and process the data indicated herein for the I hereby authorize UCV to collect and process the data indicated herein for the
purpose of effecting control of the COVID-19 infection. I understand that my personal purpose of effecting control of the COVID-19 infection. I understand that my personal
information is protected by RA 10173, Data Privacy Act of 2012, and that I am information is protected by RA 10173, Data Privacy Act of 2012, and that I am
required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature:_________________________ Date:__________________ Signature:_________________________ Date:__________________