University of the Immaculate Conception

College of Medical and Biological Sciences

Fr. Selga St., Davao City 8000, Philippines
|Tel nos. (02) 221 -8090 (loc. 118)| Fax .: (63-082) 226-2676|

INTERN’S HEALTH DECLARATION FORM

This form is for the safety and protection of everyone in this time of COVID-19 pandemic. This is to screen all INTERNS who
wish to participate in the internship training program or in entering all affiliated facilities. The information herein will be used in
accordance with law and to contact you in cases of any transmission of communicable disease. This form shall be kept with
confidentiality and with privacy.
KINDLY FILL OUT COMPLETELY and ACCURATELY

Date: _05-05--22____________ Temperature: _____36.5________

SURNAME FIRST NAME MIDDLE NAME SUFFIXES

Catedral Jan Micah Apilan

CURRENT ADDRESS

House #/Street Zone/Subdivision Barangay City/Municipality

Llego residence, 39-D Davao City

Washington St.

Province Other Details

Contact #: 09204852807

Email Address Jcatedral_180000000895@uic.edu.ph

PLEASE CHECK THE BOX

Sore throat [] Yes [ /] No

Fever [] Yes [/ ] No
DO YOU
Cough [] Yes [/ ] No

Runny Nose [] Yes [/ ] No

EXPERIENCE
THE
Loss of sense of smell [] Yes [/ ] No
FOLLOWING?
 Loss of sense of taste [] Yes [/ ] No

Abdominal pain [] Yes [ /] No

Diarrhea [ ] Yes [ /] No
DO YOU HAVE RECENT TRAVEL? [] Yes [ /] No

IF YES, STATE WHERE:

IF YES, what is the quarantine status of the area visited?

IF YES, State date of return to residence

Do you have Contact with a probable or confirmed case? [ ] yes [ ] no

exposure that
includes Worked in or attended a facility with probable or confirmed case? [ ] yes [ ]/ no

SIGNATURE

VERIFIED BY:
(w/ signature)