CEBU CITY COVID-19 VACCINE REGISTRATION FORM

*Required
01 – Health Care Worker 02 – Senior Citizen
1. CATEGORY*
03 – Indigent 04 – Uniformed Personnel
(pls. write number on box)
05 – Essential Worker 06 – Other
2. CATEGORY ID* 01 – PRC Number 02 – OSCA Number ID Number:
ID number depending on 03 – Facility ID number 04 – PWD ID
category type 05 – Other ID * Please Check the answer
3. Philhealth ID Number*
Social Pension Grantee?
4. Social Pension
01 – Yes 02 – No
5. Last Name*
First Name*
Middle Name*
Suffix
6. Contact Number*
(mobile) 09XXXXXXXXX
7. Full Address:
(House No./Street/Sitio)
Province*
Municipality/City*
Barangay*
Sitio*
8. Sex at Birth* 01 – Female 02 - Male

9. Birthday* (mm/dd/yyyy)
01 – Single 02 – Married
10. Civil Status* 03 – Widow/Widower 04 – Separated/Annulled
05 – Living with Partner
01 – Government Employed 02 – Private Employed
11. Employed* 03 – Self-employed 04 – Private Practioner
05 - Others
01 – Unemployed 02 – Volunteer
If Others* 03 – Student

01 – Dental Hygienist 02 – Dental Technologist

12. Profession*
Providing direct COVID care*
13. Name of Employer*
Governmental Unit of
Employer (e.g. Cebu City)*
Employer Address*
Employer Contact No.*
03 – Dentist 04 – Medical Technologist
05 – Midwife 06 – Nurse
07 – Nutritionist/Dietician 08 – Occupational Therapist
09 – Optometrist 10 – Pharmacist
11 – Physical Therapist 12 – Physician
13 – Radiologic Technologist 14 – Respiratory Therapist
15 – X-ray Technologist 16 – Barangay Health Worker
17 – Maintenance Staff 18 – Administrative Staff
19 - Other
Are you providing direct COVID care?
01 – Yes 02 - No
 If female, pregnancy status, If Male choose 02 – Not pregnant
14. Pregnancy Status* 01 – Pregnant 02 – Not pregnant

01 – Yes 02 - None
15. History of Allergy*

01 – Drug 02 – Food
03 – Insect 04 – Latex
Type of Allergy*
05 – Mold 06 – Pet
07 – Pollen

If Other allergy, please specify

With Comorbities
16. Comorbidities* (Y/N) 01 – Yes 02 – No
01 – Hypertension 02 – Heart Disease
03 – Kidney Disease 04 – Diabetes Mellitus
If yes, List of comordibities*
05 – Bronchial Asthma 06 – Immunodeficiency State
07 – Cancer 08 – Others
Have you been diagnosed with COVID-19?
17. COVID History* 01 – Yes 02 – No
COVID Date
(date of first positive result)
(mm/dd/yyyy)
01 – Asymptomatic 02 – Mild
COVID Classification 03 – Moderate 04 – Severe
05 – Critical
18. Provided electronic 01 – Yes 02 - No
informed consent?
(Website: mics.cebucity.gov.ph/vims)*

Agreed to be vaccinated?
19. Consent* 01 – Yes 02 – No
03 – Undecided

Cebu City Data Privacy Policy

Statement of Policy

The Cebu City Government is hereby committed to respect and protect the personal information of its constituents and general
public by adhering to Republic Act 10173, otherwise known as the Data Privacy Act of 2012 and other related laws.

This Privacy Notice of the Cebu City Government (CCG) is applicable to all personal information that we collect and process on
all CCG forms. Personal Information refers to any information, whether recorded in a material form or not, from which your
identity can be reasonably and directly identified. Sensitive personal information includes the individual’s race, ethnic origin,
marital status, age, color, religious, philosophical or political affiliations, health, education genetic or sexual life of a person, or
to any proceeding for any offense committed or alleged to have been committed by such person, the disposal of such
proceedings, or the sentence of any court in such proceedings and those issued by government agencies peculiar to an
individual which includes, but not limited to, social security numbers, previous or current health records, licenses or its denials,
suspension or revocation, and tax returns.

Rights of Data Subjects

Pursuant to the Data Privacy Act of 2012 and other related laws, CCG is obliged and duty bound to protect and respect your
privacy rights, including the right to be informed, right to access, right to correct, right to erasure or blocking, right to damages,
right to file a complaint, right to rectify and right to data portability.

I hereby declare that all information given above is true to the best of my knowledge and belief.

Signature: ____________________________________________ Date: ________________________________