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Himamaylan City Health Declaration Form

This document is a health declaration form from the Department of Education in Region VI - Western Visayas, Philippines. It collects health information from Diana Joy L. Abarquez, including whether she has experienced any COVID-19 symptoms, had contact with confirmed cases, or traveled outside the region. She authorizes DepEd to collect and process this data to control the spread of COVID-19, and acknowledges her requirement to provide truthful information under relevant laws. The form is then verified by an additional signature.

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Yanna Abarquez
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38 views1 page

Himamaylan City Health Declaration Form

This document is a health declaration form from the Department of Education in Region VI - Western Visayas, Philippines. It collects health information from Diana Joy L. Abarquez, including whether she has experienced any COVID-19 symptoms, had contact with confirmed cases, or traveled outside the region. She authorizes DepEd to collect and process this data to control the spread of COVID-19, and acknowledges her requirement to provide truthful information under relevant laws. The form is then verified by an additional signature.

Uploaded by

Yanna Abarquez
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

Republic of the Philippines

Department of Education
REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF HIMAMAYLAN CITY

HEALTH DECLARATION FORM


Date & Time: May 17, 2021

Name: DIANA JOY L. ABARQUEZ


Address: Purok Rizal, Barangay Talaban, Himamaylan City, Negros Occidental
Office/School: Schools Division of Himamaylan City
Contact Number: 09386477825/09669212276

Instruction: Please put CHECK MARK ( ) YE


NO
S
1. Are you experiencing: (nakakaranas ka ba ng:) /

a. Sore Throat (pananakit ng lalamunan/masakit 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 close environment of a
confirmed COVID-19 case?
(May nakasama kaba or nakatrabahong tao na kumpirmadong may COVID-19/may
impeksyon ng coruna 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 o sakit ng lalamunan sa
nakalipas ng dalawang (2) lingo?)

4. Have you travelled outside the Philippines in the last 14 days? /


(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw)
5. Have you travelled to any area in Region VI aside from your home? /
(Ikaw ba ay nakapunta sa iba pang parte ng Region VI o Western Visayas bukod sa
inyong bahay?)
Specify (Sabihin kung saan):

I hereby authorize DepEd-SDO Himamaylan City, to collect and process the data indicated herein
for the purpose of effecting control of COVID-19 infection. I understand that my personal
information is protected by RA 10173, Data Privacy Act of 2012, and I am required by RA 11469,
Bayanihan to Heal as One Act, to provide truthful information.

DIANA JOY L. ABARQUEZ

Signature over Printed Name Verified by and Signature over Printed Name

Address: Vallega St., Brgy. I-Poblacion, Himamaylan City


Telephone: (034) 744-6276
Email Address: [Link]@[Link]

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