Republic of the Philippines CONTROL NO:

Province of Ilocos Sur DATE:

COVID Action Center
Vigan City TIME:
***Kindly PRINT all details legibly

HEALTH DECLARATION & UNDERTAKING

NAME: ______________________________________________________________________________ AGE: ___________ GENDER: __________
PROVINCIAL ADDRESS: ___________________________________________________________________________________________________
CONTACT NUMBER: _________________________________________________ OCCUPATION: ________________________________________
POINT OF ORIGIN: Local ____________________________________________ Foreign _______________________________________________
TRAVEL HISTORY: DOMESTIC INTERNATIONAL
E
COVID-19 SYMPTOMS (if with symptom/s hold and refer to the nearest Isolation Facility):
BODY TEMPERATURE _______⁰C SORE THROAT
HEADACHE DIARRHEA
COUGH DIFFICULTY OF BREATHING
COLDS OTHERS: ___________________________________________

TRANSPORTATION: PRIVATE VEHICLE PLATE NO.: _________________________________________

ASSISTED BY GOV’T AGENCY BUS PLATE NO.: _____________________________________

***Tick the Category of Individual entering Ilocos Sur and fill-up necessary details

APOR CARGO PASSERS BY /

REQUIREMENTS ROF LSI
OTHERS
IDENTIFICATION CARD
1 / CERTIFICATE OF
EMPLOYMENT

2 TRAVEL AUTHORITY

HEALTH CERTIFICATE /
3 HEALTH PASS

TEST RESULT RDT NEGATIVE RDT NEGATIVE RDT NEGATIVE RDT NEGATIVE RDT NEGATIVE
4
(encircle) RT-PCR POSITIVE RT-PCR POSITIVE RT-PCR POSITIVE RT-PCR POSITIVE RT-PCR POSITIVE
CERTIFICATE OF
5 QUARANTINE
No. of Days:
COMPLETED YES
6 QUARANTINE PERIOD NO
No. of Days:

7 COMPANY / AGENCY

8 COMPANY ADDRESS

COMPANY CONTACT
9
NUMBER
TRAVEL ORDER /
10 MISSION ORDER
SALES INVOICE /
11
DELIVERY RECEIPT
NO. OF DRIVER /
PASSENGERS /
CREW
12 NAMES OF PASSENGERS
AND CREW

13 PURPOSE

14 DESTINATION

DURATION OF STAY IN
15
THE PROVINCE

I hereby declare that the information disclosed above are true, correct and complete. I understand that failure to answer
truthfully may have serious consequences in accordance with R.A. 11332.

______________________________________________
Signature over Printed Name

_________________________________________ ***To be filled-up by PDRRMC Officer

Signature over Printed Name STATUS REPORT

Philippine National Police Officer / Bureau of Fire Protection Officer
PHASE I: DOCUMENTATION, HEALTH CHECK & INSPECTION ALLOWED ENTRY
DENIED ENTRY
_________________________________________ INCOMPLETE DOCUMENTS
Signature over Printed Name
TEMPORARY HOLD
Provincial Disaster Risk Reduction Management Officer
PHASE II: VALIDATION & COORDINATION BACK TO ORIGIN