Accomplished form to be submitted upon return to school.

As part of the precautionary measures against COVID-19, kindly fill-out a declaration of your travel and health status.

To be accomplished at home and submitted by students upon return to school.

PERSONAL INFORMATION
Full Name: Contact Number:

Address:

Grade /Year Track / Program

TRAVEL DECLARATION AND VISIT INFORMATION

Please state the cities that you have visited in the 14 days prior this meeting/event and the dates of your travel.
Date of Entry Date of Exit
City (If outside the Philippines, include also in the list below)
(dd/mm/yyyy): (dd/mm/yyyy):
1
2
OTHER DECLARATION
Please tick the box for each item YES NO
1 You or any member of your household / roommate have returned from
foreign/local travel in the fourteen (14) days prior to this date ☐ ☐
2 You or any of member of your household / roommate are currently under a
☐ ☐
quarantine order
3 You have been in close contact with a confirmed case of COVID-19 in the
☐ ☐
fourteen (14) days prior to this day
4 You are experiencing any of the following symptoms:
☐ ☐
a. Temperature of 37.6 degrees Celsius or higher
b. Cough and runny nose ☐ ☐
c. Sore throat ☐ ☐
d. Shortness of breath ☐ ☐
e. Headaches ☐ ☐
f. Gastrointestinal upset ☐ ☐
g. Lethargy/fatigue/tiredness/body aches ☐ ☐

____________________________________________
Student’s signature over printed name

____________________________________________
Guardian’s signature over printed name

PRIVACY NOTICE
In line with STI’s compliance with Data Privacy Act, any information declared in this form will be used solely for
evaluation on possible exposure to COVID-19.