Republic of the Philippines

Department of Agriculture
Philippine Center for Postharvest Development and Mechanization
Science City of Muñoz, Nueva Ecija, Philippines
www.philmech.gov.ph

NOTICE: DA-PHilMech is strictly implementing a "NO-FACE-MASK-NO-ENTRY" policy. Wear your face mask at all
times while inside the DA-PHilMech premises. Kindly accomplish the attached form. Rest assured that the
information you have shared will be treated with strict confidentiality and shall be used for the DA-PHilMech's Safety
and Contact Tracing purposes only.

HEALTH DECLARATION FORM

Name:
Last Name First Name Middle Name
Nationality: Sex: Age: Contact No.
Email Address:
Present Address :
Temperature:
Foreign countries you have worked, visited, transited or
travelled to in the past 14 days?

Cities in the Philippines you have worked, lived, or

transited for the past 14 days

Have you been sick in the past 30 days? Hospital visited: If yes, please describe condition: No
_______________________________________________________

If yes, please specify: ____________________ No

Do you have fever, colds, cough, sore throat, loss of smell
and taste, muscle pain, headache and difficulty in breathing
for the past 14 days?
Have you been in closed contact or exposed to any person If yes, please decribe circumstance: No
suspected of or confirmed with communicable disease?

Have you been in close contact with farm animals or If yes, please decribe circumstance: No
exposed to wild animals?

Declaration and Data Privacy Consent Form:

Declaration: The information I have given is true, correct and complete. I understand that failure to answer any question
or giving falsified response may have serious consequence and can be penalized in accordance with law. I voluntarily and
freely consent to the collection and sharing of the above personal information only in relation to the safety protocols of
DA-PHilMech.

Name and Signature Date

PHilMech-IM-F-074 Rev. 00 (06.04.20)