Scribd Logo
Upload

Welcome to Scribd!

  • 4 views

    Health Survey Form COVID 19

    Uploaded by

    Joe Bernardo
    The document is a health survey form asking individuals questions about COVID-19 symptoms and potential exposure over the past 10 days and 24 hours. It requests travel history, contact with COVID patients, attendance at gatherings, and vaccination status. Respondents must certify that their answers are true and honest.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Health Survey Form COVID 19

    Uploaded by

    Joe Bernardo
    4 views1 page
    The document is a health survey form asking individuals questions about COVID-19 symptoms and potential exposure over the past 10 days and 24 hours. It requests travel history, contact with COVID patients, attendance at gatherings, and vaccination status. Respondents must certify that their answers are true and honest.

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document is a health survey form asking individuals questions about COVID-19 symptoms and potential exposure over the past 10 days and 24 hours. It requests travel history, contact with COVID patients, attendance at gatherings, and vaccination status. Respondents must certify that their answers are true and honest.

    Copyright:

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

    Health Survey Form COVID 19

    Uploaded by

    Joe Bernardo
    The document is a health survey form asking individuals questions about COVID-19 symptoms and potential exposure over the past 10 days and 24 hours. It requests travel history, contact with COVID patients, attendance at gatherings, and vaccination status. Respondents must certify that their answers are true and honest.

    Copyright:

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

    Republic of the Philippines

    Department of the Interior and Local Government


    BUREAU OF FIRE PROTECTION
    REGIONAL OFFICE III
    DMGC, Bgry. Maimpis, City of San Fernando, Pampanga.
    Telefax No. 0943-700-3136
    Email address: [email protected]

    HEALTH SURVEY FORM

    All information provided in this form shall be covered by RA Republic Act 10173 or the Data
    Privacy Act of 2012, hence, will not be disclosed to anyone

    Please answer the following questions truthfully and all with honesty:

    ( Answerable by Yes or No, put a  mark on the box provided)

    A. Do you have the following conditions/symptoms for the last 24 hours?


    (Mayroon ka ba ng mga sumusunod na karamdaman/sintomas sa nakalipas na 24
    Yes No
    oras?)
    a. Fever (Lagnat), equal or more than 38ºC
    b. Coughs, Colds, Sore Throat or Loss of taste or smell (ubo, sipon /pananakit ng
    lalamunan o nawalan nang panlasa o pang amoy)
    c. Difficulty of breathing (hirap sa paghinga)

    B. For the last 10 days (sa nakalipas na 10 na araw) ikaw ba ay:

    a. Have travel history to other province/region/country?


    1. Where? (Saan?) ________________________________
    2. When? (Kailan?) ________________________________
    3. Date of Arrival? ________________________________

    b. Have travel history to areas with positive/active COVID-19 case?


    1. Where? (Saan?) ________________________________
    2. When? (Kailan?) ________________________________
    3. Date of Arrival? ________________________________

    c. Have you in contact with a confirmed COVID-19 patient or visited a hospital with
    confirmed COVID-19 patient?
    1. Where? (Saan?) ________________________________
    2. When? (Kailan?) ________________________________
    3. Date of Arrival? ________________________________

    d. Have attended various gatherings such as birthday party/wake/social/ religious


    services?
    1. Where? (Saan?) ________________________________
    2. When? (Kailan?) ________________________________
    3. Date of Arrival? ________________________________

    e. Fully vaccinated with COVID-19 vaccine?


    1. Brand and date of 1st dose? ________________________________
    2. Brand and date of 2nd dose? ________________________________
    3. Acquired from (saan nabakunahan? ________________________________
    4. Do you have a booster shot? ________________________________
    (if YES, indicate brand and date of vaccination)
    I certify that the GIVEN information above are true and correct to the best of my
    knowledge.

    __________________________________________
    Signature over Printed Name
    Address: ___________________________________
    Contact Number: _____________________________
    Date: ______________________________________

    You might also like