Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

REGION XI REGION XI
DIVISION OF DAVAO DE ORO DIVISION OF DAVAO DE ORO
MONKAYO EAST DISTRICT MONKAYO EAST DISTRICT
BABAG NATIONAL HIGH SCHOOL BABAG NATIONAL HIGH SCHOOL

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

(Grade 8 – Ruby)
(Grade 8 – Ruby)
Name: ____________________________________
Name: ____________________________________
Address: __________________________________
Address: __________________________________
Sex: Male ____ Female ____ Age: ________
Sex: Male ____ Female ____ Age: ________
Contact Number:____________________________
Contact Number:____________________________
Temperature: __________ Date: ______________
Temperature: __________ Date: ______________

Yes No
Yes No
a. Sore Throat
a. Sore Throat (pananakit ng lalamunan/
(pananakit ng lalamunan/ 1. Are you
1. Are you masakit lumunok)
masakit lumunok) experiencing
experiencing b. Body Pains
b. Body Pains (Nakakaranas ka (pananakit ng katawan)
(Nakakaranas ka (pananakit ng katawan) ba nang ) c. Headache
ba nang ) c. Headache (pananakit ng ulo)
(pananakit ng ulo)
d. Fever for the past
d. Fever for the past
few days
few days (lagnat sa mga nakalipas na
(lagnat sa mga nakalipas na araw)
araw)
2. Have you worked together or stayed in
2. Have you worked together or stayed in
the same close environment of a confirmed
the same close environment of a confirmed
COVID 19 case? (May nakasama ka bang o
COVID 19 case? (May nakasama ka bang o nakatrabahong tao na kumpirmadong may COVID 19/may
nakatrabahong tao na kumpirmadong may COVID 19/may impeksyon na corona virus?)
impeksyon na corona virus?)
3. Have you had any contact with anyone
3. Have you had any contact with anyone
with fever, cough, colds, and sore throat in
with fever, cough, colds, and sore throat in
the past 2 weeks? (Mayroon ka bang nakasama na
the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon, o sakit sa lalamunan sa nakalipas
may lagnat, ubo, sipon, o sakit sa lalamunan sa nakalipas na dalawang (2) linggo?)
na dalawang (2) linggo?)
4. Have you travelled to any area in Region
4. Have you travelled to any area in Region
XI in the last 14 days? Specify ___________
XI in the last 14 days? Specify ___________ (Ikaw ba ay nakapagbiyahe sa ibang parte ng Rehiyon XI
(Ikaw ba ay nakapagbiyahe sa ibang parte ng Rehiyon XI sa nakalipas na 14 na araw? Sabihin kung saan _______)
sa nakalipas na 14 na araw? Sabihin kung saan _______)
5. Have you travelled to any area outside
5. Have you travelled to any area outside
Dave De Oro in the last 14 days? Specify
Dave De Oro in the last 14 days? Specify
________ (Ikaw ba ay nakapagbiyahe sa labas ng
________ (Ikaw ba ay nakapagbiyahe sa labas ng Davao De Oro sa nakalipas na 14 na araw? Sabihin kung
Davao De Oro sa nakalipas na 14 na araw? Sabihin kung saan: ______________ )
saan: ______________ )

I hereby authorized Babag National High School to

I hereby authorized Babag National High School to
collect and process the data indicated herin for the
collect and process the data indicated herin for the
purpose effective control of COVID-19 infection. I
purpose effective control of COVID-19 infection. I
understand that my personal information is protected
understand that my personal information is protected
by RA 10173, Data Privacy Act of 2012, and that I am
by RA 10173, Data Privacy Act of 2012, and that I am
required by RA 11469, Bayanihan to Heal As One Act
required by RA 11469, Bayanihan to Heal As One Act
to provide truthful information.
to provide truthful information.

__________________________________________
__________________________________________
Signature Over Printed Name (Pangalan/Pirma)
Signature Over Printed Name (Pangalan/Pirma)

Date Signed: _________________

Date Signed: _________________