Republic of the Philippines

Department of Education
CARAGA REGION XIII
SCHOOLS DIVISION OF SURIGAO DEL NORTE

HEALTH DECLARATION CHECKLIST

Name: ___________________________________ Date: _____________________

Office: ___________________________________ Designation:________________
Contact Number: ___________
FOR THE PAST 2 WEEKS:

TRAVEL
Yes No
Abroad ___ ____ When/ Where: _________________________
Local ___ ____ When/ Where: _________________________
______________________________________
In contact with someone
Travelled outside SDN ___ ____ When/ Where: _________________________
Relationship: __________________________
Been in any location/ site ___ ____
declared as potentially No. of Days: __________________________
Infective with COVID-19

Attended gatherings ___ ___ What: __________________________

When: __________________________
Where: __________________________
Experience signs and symptoms like:
Yes No
Fever ___ ___ Temp: ______
Colds ___ ___ Date symptoms started: _________________
Cough ___ ___
Sore throat ___ ___
Difficulty of Breathing ___ ___
Fatigue ___ ___
Diarrhea ___ ___

The information I have provided about my medical history is accurate to best of my

knowledge. I agree to accept responsibility for any omission in disclosing my existing or past
medical condition.
I also commit to inform my superior and the health section about any symptoms that
may arrive after having filed this declaration and/ or having in contact with someone tested
positive after signing this declaration.

______________________________
Signature over printed name.

Address: Rizal St. Cor. Peñaranda St., Surigao City

Telephone: (086) 826-82-16