APPLICATION FOR HOME QUARANTINE COMPLIANCE

Province of Cavite
Ako si ________________________, may edad na _____ na taong gulang, at naninirahan sa Barangay Municipality of Silang
_________________________, Silang, Cavite, ay nagsasaad na: Municipal Health Office
1. Ako ay sumunod sa Home Quarantine Procedure nang hindi bababa sa 14 naaraw.
2. Ako ay namalagi sa (actual physical address)_______________________________________ at
hindi lumabas ng nasabing lugar sa panahon ng aking quarantine. Certificate of Home Quarantine Compliance
3. Na ako ay walang sintomas ng Covid-19 at ako ay nasa mabuting pangangatawan at kalagayan.
4. Na ang akingsi naad ay kumpleto at totoo, at naiintindihan kona ako ay maaring makulong,
This is to certify that Mr./ Ms. _________________________, _______years
magmulta, at ipaulit ang aking quarantine nang naayon sa batas.
old, resident of Barangay ______________________, Silang, Cavite has completed
pirma his/her mandatory_____day home quarantine as required under Department Circular
No. 2022-0002.
pangalan
Furthermore, the above named is:
(thumb mark) date
( ) Not yet vaccinated
( ) Partially vaccinated with ______________________ vaccine on ___________________
at ______________________ vaccination center.
BHERT CERTIFICATION
( ) Fully vaccinated with _________________________ vaccine on ___________________
at_______________________vaccination center.
Kami, si Punong Barangay _Mario M. Marqueses_ at RHM _Ma. Dolores L. Lumagda_, mgakinatawan
( ) With booster dose of __________________________ vaccine on ___________________
ng Barangay Health Emergency and Response Team ng Barangay _Puting kahoy_, Silang, Cavite, ay
at _______________________ vaccination center
nagpapatunay na ang applicant nanasaad ay na-monitor ang Quarantine protocol, at siya ay hindi
gumawa ng kahit na anung paglabag sa nasabing direktiba. Ito ay aming pinagtitibay ayon sa aming
This is to further certify that the above-mentioned did not develop any signs
sinumpaang tungkulin, at aming naiintindihan na kami ay maaring managot sa kinauukulan para sa
kahit anung di-makatotohanang pag-ulat naayon sa batas. or symptoms for Covid-19 as of the date of issuance of this certificate.

Silang, Cavite.,
Yr 2022.

Punong Barangay Midwife/Nurse

Angel Marqueses -Casapao M.D.
Action taken by the Quarantine Officer Quarantine Officer

[ ] application approved [ ] deferred for _____ days

Control No. For further evaluation by:
Important Notice: The above-mentioned is however still enjoined to comply with all health and security protocols and

Republic of the Philippines

should immediately report any symptom or adverse condition to his/her Barangay Health Emergency and Response
Team (BHERT) or the Local Government’s Health Unit where he/she may be residing or located.