Republic of the Philippines

Department of Education
REGION X
SCHOOLS DIVISION OF OZAMIZ CITY
MARCELINO C. REGIS INTEGRATED SCHOOL
S.Y 2022 - 2023
DAILY HEALTH DECLARATION FORM
Month : August
Dear Learners:
To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple
screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this agency.
Thank you for your time.

Name: ___________________________________________ Grade & Sec:__________________________

Age: ___________________________ Sex: _____________
Personal Contact No.: ________________________________
Home Address:__________________________________________
Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp. Date Temp.
Symptom
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Fever
Cough
Sore throat
Diarrhea
Body aches
Headache
Dry cough
Tiredness
Shortness of breath
Runny nose
Other Symtoms
1
2
3

Have you been in

contact with a
confirmed COVID-19
patient in the past 14
days?

Have you been

indentified to high risk
areas of COVID-19 in the
past 14 days? If Yes,
please indicate the area
(s):

Declaration and Data Privacy Consent Form:

The information I have given is true, correct and complete. I understand that failure to asnwer any question or giving false answer can be penalized in accordance with law.
I voluntary and freely consent to the collection and sharing of the above personal information only in relation to the DepEd Ozamiz City COVID-19 internal protocols.

Signature

Please be advised that the above information shall only be used in relation to DepEd COVID-19 internal protocols in accordance with the Data Privacy Act.