Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Vice President for Administration
Medical Servics Department

POLYTECHNIC UNIVERSITY
OF THE PHILIPPINES
MEDICAL SERVICES
DEPARTMENT
HEALTH DECLARATION CHECKLISTF
For your own protection and safety
of your family and the PUP community,
please accomplish this form
truthfully and completely.
Thank you.

NAME: DATE:
Student Faculty Employee

YES NO Questions:
TRAVEL HISTORY
For the last 14 days, did you travel to a country or
a place with high number of COVID-19 patients?
COUNTRY, CITY, or PROVINCE:_______
FEVER>38C DATE OF ONSET:________
COUGH AND/OR COLDS DATE OF
ONSET:______
Did you have any close contact or interaction
with any of the following:
 Individuals providing direct care. and/or
working with individuals infected with
COVID-19, and/or visiting or staying in
the same environment with COVID-19
patient
 In close proximity or shared the same
room with a COVID-19 patient
 Travelled together with COVID-19
patient
 Living with a COVID-19 patient within a
14-day period after the onset of his/her
symptoms

PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila 1016

Direct Line: 335-1745|Trunk Line: 335-1787 or 335-1777 local 385 (Medical Director’s Office, 312 (Clinic)
Website: www.pup.edu.ph| Email: medical@pup.edu.ph

THE COUNTRY’S 1st POLYTECHNICU

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