Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City 2700 Ilocos Sur

University Clinic
Medical Services Office
Website: www.unp.edu.ph email: medical_dental@unp.edu.ph
TelNo.: 0947-8934563

HEALTH DECLARATION FORM

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to
transmit disease from person to person through respiratory droplets, our goverment has set recommendations, guidelines, and
some prohibitions which the University of Northern Philippines adheres to comply. In consideration of my participation in the
program, the undersigned acknowledges and agrees with the following details by putting a check mark in the box before each
statement.

I am aware of the existence of the risk of my physical appearance to the venue of my participation to the activity of the
University that may cause illness such as, but not limited to COVID-19.

I have not experienced signs and symptoms related to COVID-19 such as fever, headache, cough, cold, fatigue,
diarrhea, and difficult of breathing within the last 14 days.

I have not, nor any member of my household recently travelled internationally.

I did not, nor any member of my household recently visit any area within the Philippines that was reported to be highly
affected by COVID-19.

I have not been, nor any member of my household, recently suspected to be infected with COVED-19 virus.

I hereby authorize the University Clinic to collect the data indicatied herein for the purpose of contacting tracing and to control the
transmission of COVID-19. I also understand that my personal information is protected by R.A. 10173 or the Data Privacy Act of
2012.

Date of Visit: Time of Visit:

Name: Jay Marvin Q Manggad Temperature:

Complete Address: Puro, Caoayan, Ilocos Sur

Cellphone Number: (+63) 961-299-0802 Signature:

*This form will remain effective until laws and mandates relevant to COVID-19 are lifted.