HEALTH DECLARATION CHECKLIST FORM Body temperature: 1st Temperature Reading

2nd Temperature Reading

Name: Sex: Age:

Residence Address:
Nature of Official Transaction:
Office/ Person to Visit:
Please answer the following: YES NO
1. Are you experiencing:
a. Sore throat?
b. Body pains?
c. Headache?
d. Fever in the past few days?
2. Have you worked together or stayed in the same
environment of a confirmed COVID-19 case?
3. Have you had any contact with anyone with fever,
cough, shortness of breath, colds and sore throat
in the past two weeks?
4. Have you arrived from abroad in the last 14 days?
5. Have you travelled to any area in NCR in the last 14 days?

I hereby AUTHORIZED Department of the Interior and Local Government Region 3 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 protected
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.

Signature: _ Date: _

HEALTH DECLARATION CHECKLIST FORM Body temperature: 1st Temperature Reading

2nd Temperature Reading

Name: Sex: Age:

Residence Address:
Nature of Official Transaction:
Office/ Person to Visit:
Please answer the following: YES NO
6. Are you experiencing:
a. Sore throat?
b. Body pains?
c. Headache?
d. Fever in the past few days?
7. Have you worked together or stayed in the same
environment of a confirmed COVID-19 case?
8. Have you had any contact with anyone with fever,
cough, shortness of breath, colds and sore throat
in the past two weeks?
9. Have you arrived from abroad in the last 14 days?
10. Have you travelled to any area in NCR in the last 14 days?

I hereby AUTHORIZED Department of the Interior and Local Government Region 3 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 protected
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.

Signature: _ Date: _