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Health Declaration for School Visitors

This document is a health declaration form used by the Inasuyan Integrated School in Biliran, Philippines to screen employees, visitors, and parents for COVID-19 symptoms and exposure. It asks individuals if they have experienced common COVID-19 symptoms in the past 14 days, if they have been in close contact with a confirmed COVID-19 case, if they have traveled outside the country or city in the past 14 days, and requires them to certify that their responses are true. The form collects contact information and health details to help prevent the spread of COVID-19 within the school community.

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Jenevey Alcober
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33 views1 page

Health Declaration for School Visitors

This document is a health declaration form used by the Inasuyan Integrated School in Biliran, Philippines to screen employees, visitors, and parents for COVID-19 symptoms and exposure. It asks individuals if they have experienced common COVID-19 symptoms in the past 14 days, if they have been in close contact with a confirmed COVID-19 case, if they have traveled outside the country or city in the past 14 days, and requires them to certify that their responses are true. The form collects contact information and health details to help prevent the spread of COVID-19 within the school community.

Uploaded by

Jenevey Alcober
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 VIII-EASTERN VISAYAS
SCHOOLS DIVISION OFFICE OF BILIRAN
INASUYAN INTEGRATED SCHOOL
INASUYAN, KAWAYAN, BILIRAN

Health Declaration Form


Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY):
Time (Oras):
Complete Current Address (Kasalukuyang tirahan):

Mobile/ Phone Number (Numero ng Telepono):


Email Address:
Put a check mark on the appropriate column of your response (Lagyan ng tsek sa angkop na sagot.)
Yes (Oo) No
(Hindi)
1. Are you experiencing, or a. Fever (Lagnat)
did you have any of the b. Cough and/ or Colds (Ubo at/ o sipon)
followinging in the last 14
days? (Ikaw ba ay may
nararanasan o nakaranas
c. Body pains (Pananakit ng Katawan) Health Declaration form for
d. Sore throat (Pananakit o pamamaga ng lalamunan)
ng mga sumusunod na
sintomas sa nakaraang 14
na araw?
e. Fatigue or Tiredness (PAgkapagod) Employees, Visitors and Parents.
f. Headache (Pananakit ng Ulo)
g. Diarrhea (Pagatatae)
h. Loss of taste or smell (Nawalan ng panlasa o
pangamoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
2. Have you had face-to-face contact with a probable or confirmedCOVID-19 case within
1 meter and fore more than 15 minutes for the past 14 days? (May nakasalamuha ka ba
na maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansya or mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14
araw?)
3. Have you provided direct care for a patient with probable or confirmed COVID-19
case without using proper “Personal Protective Equipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?)
4. Have you traveled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe
sa labas ng Pilipinas sa makalipas na 14 na araw?
5. Have you traveled outside the current city/ municipality where you reside? (Ikaw ba
ay nagbiyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify which
city/municipality you went to (Sabihin kung saan): __________________

I hereby certify that the information given is true, correct, and complete. I understand that failure to answer any question or
any falsified response may have serious consequences. I understand that my personal information is protected by RA
10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the date of
accomplishment, following the National Achieves of the Philippines protocol.

Signature (Lagda): ____________________

INASUYAN INTEGRATED SCHOOL


Inasuyan, Kawayan, Biliran
School ID: 500411/ Email Add: 500411@[Link]

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