Republic of the Philippines

Department of Education
Region II – Cagayan Valley
Schools Division of Cagayan

HEALTH DECLARATION FORM

Temperature: __________

Name:_______________________________________ Sex: __________ Age: _________

_
Address: ______________________________________________________________________
Contact# ____________________________ School where you applied for:
________________________________________
Testing Center: ______________________ Schedule: _____________________________

Yes No
Sore throat (Pananakit ng
Are you experiencing (Nakakaranas ka lalamunan)
ba ng): Body Pains (pananakit ng
katawan)
Headache (pananakit ng ulo)
Fever for the past few days
(lagnat sa mga nakalipas na
araw)
Have you worked together or stayed in the same close environment
with a confirmed COVID-19 case. (May nakasama ka ba o nakatrabaho
na kumpirmadong may COVID-19/may impeksyon ng corona virus?)
Have you had contact with anyone with fever, cough, cold, sore throat
in the past two (2) weeks? (Mayroon ka bang nakasama na may lagnat,
ubo, sipon, o sakit ng lalamunan sa nakalipas na 2 linggo?)
Do you have travel history outside the province (i.e. Manila, etc.) in the
past 14 days? ( Ikaw ba ay nagbyahe sa labas ng probinsya (hal.
Manila, etc.) sa nakalipas na 14 na araw?)
Specify (sabihin kung saan):__________________________________________

I hereby authorize DepEd Cagayan to collect and process the data indicated
herein for the purpose of effecting control for COVID-19 infection. I understand
that my personal information is protected by R.A. 10173, Data Privacy Act of 2012
and that I am required by R.A. 11469, Bayanihan to Heal As One Act, to provide
truthful information.

___________________________________________________
Signature Over Printed Name
Date Signed ________________

Address: Regional Government Center, Carig Sur, Tuguegarao City, 3500

Telephone Nos.: PLDT (078) 377-1065; Globe Landline (078) 255-5317, (078) 255-5318
Email Address: sdo.cagayan@deped.gov.ph
Website: deped-sdocagayan.com.ph