Health Declaration Form Temperature: Health Declaration Form Temperature:
Name: _______________________________________ SEX: ___________ Age: _____________ Name: _______________________________________ SEX: ___________ Age: _____________
Residence: ___________________________________________________________________ Residence: ___________________________________________________________________
Barangay: _________________________________________ Contact No. _________________ Barangay: _________________________________________ Contact No. _________________
School Name where you applied for: ______________________________________________ School Name where you applied for: ______________________________________________
School Testing Center: ___________________________ Schedule (Date & Time): _________ School Testing Center: ___________________________ Schedule (Date & Time): _________
Please tick on the boxes Please tick on the boxes
1. Are you Yes No 1. Are you Yes No
experiencing: a. Sore throat (pananakit ng lalamunan/masakit experiencing: a. Sore throat (pananakit ng lalamunan/masakit
(nakakaranas ka ba luminok) (nakakaranas ka ba luminok)
ng:) ng:)
b. Body pains (pananakit ng katawan) b. Body pains (pananakit ng katawan)
c. Headache (pananakit ng ulo) c. Headache (pananakit ng ulo)
Fever for the past few days (lagnat sa nakalipas na Fever for the past few days (lagnat sa nakalipas na
mga araw) mga araw)
2. Hace you worked together or stayed in the same clos environment of a 2. Hace you worked together or stayed in the same clos environment of a
confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na
kumpirmadong may COVID-19 / may impeksyon ng coronavirus?) kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore 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, throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo,
sipon, o sakit ng lalamunan sa nakalipas na 14 na araw?) sipon, o sakit ng lalamunan sa nakalipas na 14 na araw?)
4. Have you traveled outside of the Philippines in the last 14 days? (Ikaw ba ay 4. Have you traveled outside of the Philippines in the last 14 days? (Ikaw ba ay
nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?) nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
5. Have you travelled to any area in NCR aside from you home? (Ikaw ba ay 5. Have you travelled to any area in NCR aside from you home? (Ikaw ba ay
nagpunta sa ibapang parte ng NCR o Metro Manila bukod sa iyong bahay?) nagpunta sa ibapang parte ng NCR o Metro Manila bukod sa iyong bahay?)
Specify (Sabihin kung saan): Specify (Sabihin kung saan):
______________________________________________ ______________________________________________
I hereby authorize DepEd - SDO Davao de Oro, to collect and process the data indicated herein for the I hereby authorize DepEd - SDO Davao de Oro, to collect and process the data indicated herein for the
purpose of effecting control of the COVID-19 infection. I understand that my personal information is prtected purpose of effecting control of the COVID-19 infection. I understand that my personal information is prtected
by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, 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. to provide truthful information.
___________________________________ ___________________________________
Signature Over Printed Name Signature Over Printed Name
Date Signed: _____________________________ Date Signed: _____________________________