HEALTH DECLARATION FORM

Full name Program

Contact number Area
Date of shift Time of shift
FOR STUDENTS
Name of Contact
parent/guardian number

Please place a check mark under your response. (Lagyan ng tesk sa angkop na sagot)
TEMPERATURE CHECKING Temp:
PHYSICAL ASSESSMENT Yes (oo) No (hindi)
1. Are you experiencing (Nakakaranas ka ba ng):
Fever (lagnat)
Cough and/or colds (ubo at/o sipon)
Body pains (pananakit ng katawan)
Sore throat (pananakit ng lalamunan/masakit lumunok)
Fatigue/Tiredness (Pagkapagod)
Headache (Pananakit ng ulo)
Diarrhea (Pagtatae)
Loss of taste or smell (Nawawalan ng panlasa o pang-amoy)
Difficulty of breathing (Pagkahapo o hirap sa pag hinga)
Dizzininess (Pagkahilo)
HISTORY CHECKING Yes (oo) No (hindi)
1. Did you have any of the symptoms above in the last 3 days? (lkaw ba ay nakaranas
ng mga sumusunod na sintomas sa nakaraang 3 na araw?)
2. Have you had face-to-face contact with a probable or confirmed COVID 19 case within
1 meter and for more than 15 minutes for the past 14 days? (May nakasalamuhaka ba
na probable or kumpirmadong pasyente na may COVID 19 mula sa isang metrong
distansya o mas malapit pa at tumatagal ng mahigit na 15 minuto sa nakalipas na 14
na araw)
3. Have you provided direct care for a patient with probable or confirmed COVID 19
case without using proper personal protective equipment for the past 14 days? (Nag-
alaga ka ba ng probable o kumpirmadong pasyente na may COVID 19 ng hindi nakasuot
ng tamang personal protective equipment sa nakalipas na 14 araw?)

I hereby authorize Gordon College-CAHS, to collect and process the data indicated herein for the purpose
of contact tracing effecting control of the COVID 19 transmission. I understand that my personal
information is protected by RA 10173 or the data privacy act of 2012.

Signed:
Signature over printed name
IMPORTANT REMINDERS:

1. The history checking of the health declaration can be answered ahead of time by the student. By
doing so, we can limit possible exposure to other students and the clinical instructor.
2. Report immediately to the CI and GC HSU if you have any symptoms in the last three days.
3. Report immediately to the CI and GC HSU if you have provided direct care or face-to-face contact
with a probable or confirmed COVID 19 case.
4. After reporting the incident, please fill out the contact tracing form.
5. The following are the Clinical Criteria COVID -19:
a) Acute onset or worsening of at least one of the following symptoms or signs:
• fever (measured or subjective), chills,
• rigors, myalgia, headache, sore throat,
• nausea or vomiting, diarrhea,
• fatigue,
• congestion or runny nose.

OR

b) Acute onset or worsening of any one of the following symptoms or signs:

• cough,
• shortness of breath, difficulty breathing, olfactory disorder, taste disorder,
• confusion or change in mental status, persistent pain or pressure in the chest, pale,
gray, or blue-colored skin, lips, or
• nail beds, depending on skin tone,
• inability to wake or stay awake.

OR

c) Severe respiratory illness with at least one of the following:

• Clinical or radiographic evidence of pneumonia,

• Acute respiratory distress syndrome (ARDS).