ATTESTATION FORM

I, ANDRE C. MALBAS, MD, Assistant Hospital Director, the duly authorized representative of Butuan
Medical Centre, do hereby declare and attest to the following:

1. That all individuals listed are part of this facility/institution of the City Government of Butuan,
Caraga Region; are among the list of the priority population; and are eligible to receive the
COVID-19 vaccine;

2. That all individuals listed in the Vaccine Information Management System- Immunization
Registry (VIMS-IR) have provided the information indicated therein with full knowledge that the
processing thereof is necessary for the generation of the masterlist for vaccination to the VIMS-
IR in order to reduce the morbidity and mortality due to COVID-19, in accordance with the
Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012;

3. That all individuals listed in the VIMS-IR Form and encoded/uploaded to the VIMS-IR have
provided the information indicated therein with expectation that the relevant government agencies
will uphold the rights of the data subjects, implement the appropriate security measures, and will
remain adherent to the general data privacy principles of transparency, legitimate purpose, and
proportionality, in processing their personal information; and

4. That all matters set forth in this VIMS-IR Form or uploaded to the VIMS-IR have been made in
good faith, duly verified by me and to the best of my knowledge and belief are true and correct.

Done this ____ day of _______________, 2021 in __________________

ANDRE C. MALBAS, MD
Assistant Hospital Director, Butuan Medical Centre

SUBSCRIBED AND SWORN to before me this 05 March 2021, at Butuan City, Philippines,
affiant exhibiting his ID _____________________ as competent evidence of his identity.

Doc. No. ______________;

Page No. _____________;
Book No. _____________;
Series of 2021.