This 3 sentence health declaration card provides identifying information and travel history for contact tracing purposes. It collects the name, contact details, address, places visited in the last 7 days, and health status of an individual named Shalanie Marie Espino Alania. By signing, the individual consents to sharing this information for COVID-19 contact tracing and confirms the information is true and accurate under Philippines law.
This 3 sentence health declaration card provides identifying information and travel history for contact tracing purposes. It collects the name, contact details, address, places visited in the last 7 days, and health status of an individual named Shalanie Marie Espino Alania. By signing, the individual consents to sharing this information for COVID-19 contact tracing and confirms the information is true and accurate under Philippines law.
This 3 sentence health declaration card provides identifying information and travel history for contact tracing purposes. It collects the name, contact details, address, places visited in the last 7 days, and health status of an individual named Shalanie Marie Espino Alania. By signing, the individual consents to sharing this information for COVID-19 contact tracing and confirms the information is true and accurate under Philippines law.
In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you will be providing in this form shall not be used for other purposes except for COVID-19 contact- tracing activities. Control no. 0d8fd fc8-0358-4de0-8d46-f7fff5e9cb20 First Name Middle Name Last Name Name SHALANIE MARIE ESPINO ALANIA Vehicle/Plate/Bus Seat ZNY718 - Number No. Mobile/Contact Destinatio No: 09099677627 SAPIAN n Address (Street/Barangay, Municipality, Province) LUCERO JAMINDAN CAPIZ Place/Province worked, visited and transited in the last 7 days. JAMINDAN
Have you been sick in the past 7 days? [ ] Yes [ ] No
Upon submitting, I am providing consent to sharing my information for contact tracing purposes, I confirm that the information I have given is true, correct and complete and that I understand failure to answer any question may have serious consequences under Philippines laws. (Article 171 and 172 of the Revised Penal Code of the Philippines) Signature of Passenger/Crew Notation by the QMO:
Signed:
Name and signature of QMO-on-Duty
Date and Time
Aklan Border Control Management App 2020 ; Maintained by APICTO - 11/25/2020 1:21:26 AM