HEALTH DECLARATION FORM* NAME (PANGALAN): NATIONALITY (KARANSANANE. AGE EDAD}. _ SEX (KASARLAN=__ OCCUPATION (IRABANION CONTACT NOMBER (MA TATAIAGANG NUMERO}: ‘LANDLINE: CELLPHON} 5. HOME ADDRESS (ADDRESS NG TAHANAN) OFFICE ADDRESS (ADDRESS NG OPISINA): EMAIL ADDRESS: 6, DATE AND PURPOSE OF VISIT (PETSA AT LAYUNIN NO PAGHISTI:1): 17. "TYPE OF VEHICLE (ORING SASAKYAN): 8, PLATE NUMBER OF VERICLE (PI_4K4 NG SASARVAN___ 9. SEAT NUMBER IF BY BUS (NUMERO NG UPUAN KUNG SUNAKAY 4-1 pusy___ 10.PLACE OF DESTINATION IN BAGUIO. CITY (UGAR Av PUPUNTAHAN/TUTULUYAN SA weGt0 erry 11, FOREIGN COUNTRIES OR OTHER REGIONS THAT YOU HAVE VISITED IN THE LAST 14 DAYS (MGA BANSANG MANYAGA 0 REHIYON Nel WONG NAPUNTAHAN 5A NARARAANG M wt AAW 12, HAVE YOU BEEN SICK OF ANY OF THE FOLLOWING IN THELAST 14 DAYS. (NAGKASAKIT KA Bl $4 MGA SUMUSUNOD SA NAKARAANG 14 Nal AR): ‘YES (00) NO (INDY FEVER CAGNAT) ‘COUGH (U0) — “COLDS (SIPONT SORE THROAT (PANANAKITNG ‘LALAMUNAN), DIFFICULTY IN BREATHING (HIRAP Sot PAGHINGA) . DIARRHEA (MAD ATAT NA PAGDUMD) DECLARATION: I hereby certify that the sbove information is wue and complete. 1 ‘understand that my failure to answer, or any false or misleading information given by mc nay ‘be used as a ground for the fling of cases against me under Asticles 171 and I72 ofthe Revised! Penal Code of the Philippines, ot Republic Act No. 11332, otherwise known as the “Law on, Reporting of Communicable Disease”. (Ako ynapepaimay naan maior mo akin bn ay telat hpi. Natit hana ka emma lig inary ay maar nig di ts paging rang crininal hon soak a ain Arce 171 ab 172 Ried Pose Cede on Republic Act No. 11332) SIGNATURE OVER NAME (PANGATAN AT PIRACA DATE (PETS) "as precautionary measre by he Cty of Baguo agsnt the tren of COVD 9, prsont to Frecination| e522, dated 6 40h 202, a the Section 16 Fhe Leal Gowen Coe.