LI

SET A
LIANGAN NATIONAL HIGH SCHOOL
 HEALTH DECLARATION FORM
____________________________

NAME: ___________________________________ GENDER: _ AGE: ______ DATES: ____________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:
I hereby give my consent to process my personal information. I certify that my declaration in this form is
true and correct and I shall fully cooperate in any evaluations or interviews arising from the information I
provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _____________________________ GENDER: ______ AGE: _____ DATES: ________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
 days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ______________________________ GENDER: ___ AGE: ____ DATES: ___________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
 past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _____________________________ GENDER: __ AGE: ____ DATES: ______________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
 COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ______________________ GENDER: ___ AGE: ___ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)
 c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _________________________ GENDER: __ AGE: __ DATES: ________________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

 1. Are you experiencing? (Naka
sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ______________________ GENDER: ____ AGE: ___ DATES: ______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________
 LIANGAN NATIONAL HIGH SCHOOL
HEALTH DECLARATION FORM
____________________________

NAME: __________________________ GENDER: __ ___ AGE: _____ DATES: _____________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:
I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ______________________ GENDER: ___ AGE: ____ DATES: ___________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?
 4. Have you travelled outside of
the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ________________________ GENDER: __ AGE: ___ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
 colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: __________________________ GENDER: ___ AGE: _____ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
 COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _________________________ GENDER: __ AGE: _ DATES: _________________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

 d. Fever for past few days
(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ________________________ GENDER: __M__ AGE: __20__ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)
 a. Sore throat (Panakit sa
tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ________________________ GENDER: ______ AGE: ____ DATES: ________________

Please mark with √ as applicable >>

 TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

 HEALTH DECLARATION FORM
____________________________

NAME: _________________________ GENDER: ___ AGE: __ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:
I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ________________________ GENDER: ______ AGE: ____ DATES: ________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
 (Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _________________________ GENDER: ___ AGE: __ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
 (Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ________________________ GENDER: ______ AGE: ____ DATES: ________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
 COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _________________________ GENDER: ___ AGE: __ DATES: _______________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

 d. Fever for past few days
(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: ________________________ GENDER: ______ AGE: ____ DATES: ________________

Please mark with √ as applicable >>

TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)
 a. Sore throat (Panakit sa
tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________

LIANGAN NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM
____________________________

NAME: _________________________ GENDER: ___ AGE: __ DATES: _______________________

Please mark with √ as applicable >>

 TEMP:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

YES NO YES NO YES NO YES NO YES NO

1. Are you experiencing? (Naka

sinati ka ba?)

a. Sore throat (Panakit sa

tutunlan)

b. Body Pains (Panakit sa

kalawasan)

c. Headache (Sakit sa ulo)

d. Fever for past few days

(Hilanat sa minglabay nga mga
adlaw)

2. Have you worked together or

stayed in the same close
environment of a confirmed
COVID 19 case?
(Naa ba ka na-kauban nga
kompirmadong nay covid 19 o
impeksyon sa Corona Virus?)

3. Have you had any contact

with anyone with fever, cough,
colds, and sore throat in the
past 2 weeks?
(Naa ba ka naka-uban nga nay
hilanat, ubo, sip-on ug panakit
sa tutunlan sa ning labay nga 2
ka semana?

4. Have you travelled outside of

the Philippines in the last 14
days?
(Naka byahe ka bas a gawas sa
Pilipinas sa ning labay nga 14
ka adlaw?)

SIGNATURE:

I hereby give my consent to process my personal information. I certify that my declaration in this form is true and
correct and I shall fully cooperate in any evaluations or interviews arising from the information I provided herein.

Signature:__________________________________________