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Department of Education: Health Declaration Form

This document is a health declaration form from Itawes National Agricultural and Technical School in the Philippines. It collects information from students such as name, age, symptoms like fever or sore throat, and travel history. It authorizes the school to collect and process this health data to help control the spread of COVID-19, while protecting student privacy under Philippine law.

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Maysie Biraquit
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74 views2 pages

Department of Education: Health Declaration Form

This document is a health declaration form from Itawes National Agricultural and Technical School in the Philippines. It collects information from students such as name, age, symptoms like fever or sore throat, and travel history. It authorizes the school to collect and process this health data to help control the spread of COVID-19, while protecting student privacy under Philippine law.

Uploaded by

Maysie Biraquit
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
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Republic of the Philippines

Department of Education
REGION II – CAGAYAN VALLEY
SCHOOLS DIVISION OF CAGAYAN
TUAO WEST DISTRICT
ITAWES NATIONAL AGRICULTURAL AND TECHNICAL SCHOOL
ITA

HEALTH DECLARATION FORM Temperature:_______

Name: __________________________________ Age: _____ Gender: ______


Year & Section: ________________________ CP#: ____________________
Address: ______________________________________
Date: ____________________ Time: ____________

SYMPTOMS YES NO
1. Are you experiencing a. Sore throat
the following: (pananakit ng lalamunan/ masakit
(Nakakaranas ka ba ng): lumunok
b. Body pains
(pananakit ng katawan)
c. Headache
(pananakit ng ulo)
d. Fever for the past few days
(lagnat sa nakalipas na mga araw)
2. Have you worked together or stayed in the same closed
environment of a confirmed COVID-19 case? (May naksama ka ba o
nakattrabahong tao na kompirmadong may COVID-19/ may
impeksyon sa corona virus?)
3. Have you had any contact with anyone with fever, cough, colds
and sore throat in the past 2 weeks? (Mayroon ka bang nakasama
na may lagnat, ubo, sipon at sakit sa lalamunan sa nakalipas na 14
na araw?
4. Have you travelled outside the Philippines in the past 14 days?
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na
araw?)
5. Have you travelled to any area in the region outside your home?
(Ikaw ba ay nagpunta sa iba pang parte ng rehiyon bukod sa iyong
bahay? Specify ( sabihin kung saan):

I hereby authorize INATS-Main to collect and process the data indicated


herein for the purpose of effecting control of the COVID-19 infection. I understand
that my information is protected by RA 10173, otherwise known as the Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as
One Act, to provide truthful information.

_____________________________

Address: Bulagao, Tuao, Cagayan, 3528


Email Address:[email protected]
Cellphone Number: 09654968755
Webpage: N/A
Republic of the Philippines
Department of Education
REGION II – CAGAYAN VALLEY
SCHOOLS DIVISION OF CAGAYAN
STO. NIÑO DISTRICT
Namuccayan integrated school
Signature Over Printed Name

Address: Namuccayan, Sto. Niño, Cagayan


Cellphone No: 09278559993 0
Email Address: [email protected]

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