Republic of the Philippines

Province of Negros Occidental

Hospital Operations Department
TERESITA L. JALANDONI PROVINCIAL HOSPITAL
Silay City

HEALTH DECLARATION
Instructions:
Please fill up legibly and accurately. In accordance with RA 11332, section 9, you are required to provide
correct information. Incorrect information or non-disclosure may be grounds for a criminal case against you.

INFORMATION:
Name: Princess F. Sugaton Age: 20
Address: Brgy. Mansilingan, Kabugwason Homes B.C. Contact no: 09617391569
Name of School/Institution: University of St. Lasalle Bacolod City

Questions: Yes No
1. Do you have:
a. Fever (Temperature 38 and above) /
b. Cough and/or runny nose /
c. Diarrhea /
d. Loss of smell /
e. Loss of taste /
f. Body aches/ Body malaise /
g. Sore throat/throat itchiness /
h. Conjunctivitis /
2. Have you been to a country/area where there are known COVID-19 cases /
in the last 14 days?
3. If yes, where? ________________________________
4. Have you been providing direct care without proper Personal Protective /
Equipment (PPE) to a known or suspected COVID-19 case in the last 14
days?
5. Have you been staying in the same close environment with a known or /
suspected COVID-19 case (including workplace, classroom,
household, gatherings) in the last 14 days?
6. Have you been travelling together in close proximity (1 meter or 3 feet) /
with
a known or suspected COVID-19 case in the last 14 days?
DECLARATION:

That I am fully aware that this is a ONE-TIME HEALTH DECLARATION intended for my week-long hospital
exposure in TLJPH.

That I am a fully vaccinated individual with BOOSTER.

That I fully understood that whenever I feel sick or has an exposure to a COVID-19 individual as stated above, I am
not allowed to report to the hospital unless a certification is presented that I am FIT TO WORK.
The information I have given is true, correct, and complete. I understand that non-disclosure or failure to provide the correct information is punishable
under RA 11332, Section 9, with a fine of P 20,000 to P 50,000, imprisonment of 1 to 6 months, or both.

________________________________________________ ____________________________________________________
Signature Over Printed Name Signature Over Printed Name/ Clinical Instructor
Date: _________________ Time: ____________________