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    Health Survey Form

    Uploaded by

    Jazel Sanchez
    This document contains a health declaration sheet used by schools to collect contact information and health status from students, staff, and visitors. The sheet collects a person's name, contact number, home address, temperature, and asks them to declare if they have any COVID-19 symptoms, if they have been in contact with someone who has COVID-19, or if they have visited affected countries in the past 14 days. The information is collected for contact tracing purposes in case someone contracts COVID-19.

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    Health Survey Form

    Uploaded by

    Jazel Sanchez
    7 views3 pages
    This document contains a health declaration sheet used by schools to collect contact information and health status from students, staff, and visitors. The sheet collects a person's name, contact number, home address, temperature, and asks them to declare if they have any COVID-19 symptoms, if they have been in contact with someone who has COVID-19, or if they have visited affected countries in the past 14 days. The information is collected for contact tracing purposes in case someone contracts COVID-19.

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    Health Survey Form Copy

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    This document contains a health declaration sheet used by schools to collect contact information and health status from students, staff, and visitors. The sheet collects a person's name, contact number, home address, temperature, and asks them to declare if they have any COVID-19 symptoms, if they have been in contact with someone who has COVID-19, or if they have visited affected countries in the past 14 days. The information is collected for contact tracing purposes in case someone contracts COVID-19.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    7 views3 pages

    Health Survey Form

    Uploaded by

    Jazel Sanchez
    This document contains a health declaration sheet used by schools to collect contact information and health status from students, staff, and visitors. The sheet collects a person's name, contact number, home address, temperature, and asks them to declare if they have any COVID-19 symptoms, if they have been in contact with someone who has COVID-19, or if they have visited affected countries in the past 14 days. The information is collected for contact tracing purposes in case someone contracts COVID-19.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    of 3

    Health Declaration Sheet for School Personnel Health Declaration Sheet for School Personnel

    NAME: CONTACT NUMBER: NAME: CONTACT NUMBER:


    HOME ADDRESS: TEMP: HOME ADDRESS: TEMP:
    SELF-DECLARATION BY VISITOR SELF-DECLARATION BY VISITOR
    1 If you have the following symptoms, please check the 1 If you have the following symptoms, please check the
    following; following;
    _____ Fever _____ Fever
    _____ Sore throat _____ Sore throat
    _____ Dry cough _____ Dry cough
    _____ Runny Nose _____ Runny Nose
    _____ Body Ache _____ Body Ache
    _____ Tiredness _____ Tiredness
    _____ Headache _____ Headache
    _____ Others _____ Others
    _____None _____None
    2 Have you been contact with confirmed COVID-19? 2 Have you been contact with confirmed COVID-19?
    ______Yes _____No ______Yes _____No
    3 Have you been to affected countries for the past 14 3 Have you been to affected countries for the past 14
    days? ______Yes _____ No days? ______Yes _____ No
    If yes, please indicate the affected countries: _________ If yes, please indicate the affected countries: _________
    Signature (visitor): ______________Date: ______________ Signature (visitor): ______________Date: ______________
    *Note: Information captured is used for contact tracing if required *Note: Information captured is used for contact tracing if required

    Health Declaration Sheet for School Personnel Health Declaration Sheet for School Personnel

    NAME: CONTACT NUMBER: NAME: CONTACT NUMBER:


    HOME ADDRESS: TEMP: HOME ADDRESS: TEMP:
    SELF-DECLARATION BY VISITOR SELF-DECLARATION BY VISITOR
    1 If you have the following symptoms, please check the 1 If you have the following symptoms, please check the
    following; following;
    _____ Fever _____ Fever
    _____ Sore throat _____ Sore throat
    _____ Dry cough _____ Dry cough
    _____ Runny Nose _____ Runny Nose
    _____ Body Ache _____ Body Ache
    _____ Tiredness _____ Tiredness
    _____ Headache _____ Headache
    _____ Others _____ Others
    _____None _____None
    2 Have you been contact with confirmed COVID-19? 2 Have you been contact with confirmed COVID-19?
    ______Yes _____No ______Yes _____No
    3 Have you been to affected countries for the past 14 3 Have you been to affected countries for the past 14
    days? ______Yes _____ No days? ______Yes _____ No
    If yes, please indicate the affected countries: _________ If yes, please indicate the affected countries: _________
    Signature (visitor): ______________Date: ______________ Signature (visitor): ______________Date: ______________
    *Note: Information captured is used for contact tracing if required *Note: Information captured is used for contact tracing if required
    Health Declaration Sheet for Students Health Declaration Sheet for Students

    NAME: CONTACT NUMBER: NAME: CONTACT NUMBER:


    HOME ADDRESS: TEMP: HOME ADDRESS: TEMP:
    SELF-DECLARATION BY VISITOR SELF-DECLARATION BY VISITOR
    1 If you have the following symptoms, please check the 1 If you have the following symptoms, please check the
    following; following;
    _____ Fever _____ Fever
    _____ Sore throat _____ Sore throat
    _____ Dry cough _____ Dry cough
    _____ Runny Nose _____ Runny Nose
    _____ Body Ache _____ Body Ache
    _____ Tiredness _____ Tiredness
    _____ Headache _____ Headache
    _____ Others _____ Others
    _____None _____None
    2 Have you been contact with confirmed COVID-19? 2 Have you been contact with confirmed COVID-19?
    ______Yes _____No ______Yes _____No
    3 Have you been to affected countries for the past 14 3 Have you been to affected countries for the past 14
    days? ______Yes _____ No days? ______Yes _____ No
    If yes, please indicate the affected countries: _________ If yes, please indicate the affected countries: _________
    Signature (visitor): ______________Date: ______________ Signature (visitor): ______________Date: ______________
    *Note: Information captured is used for contact tracing if required *Note: Information captured is used for contact tracing if required

    Health Declaration Sheet for Students Health Declaration Sheet for Students

    NAME: CONTACT NUMBER: NAME: CONTACT NUMBER:


    HOME ADDRESS: TEMP: HOME ADDRESS: TEMP:
    SELF-DECLARATION BY VISITOR SELF-DECLARATION BY VISITOR
    1 If you have the following symptoms, please check the 1 If you have the following symptoms, please check the
    following; following;
    _____ Fever _____ Fever
    _____ Sore throat _____ Sore throat
    _____ Dry cough _____ Dry cough
    _____ Runny Nose _____ Runny Nose
    _____ Body Ache _____ Body Ache
    _____ Tiredness _____ Tiredness
    _____ Headache _____ Headache
    _____ Others _____ Others
    _____None _____None
    2 Have you been contact with confirmed COVID-19? 2 Have you been contact with confirmed COVID-19?
    ______Yes _____No ______Yes _____No
    3 Have you been to affected countries for the past 14 3 Have you been to affected countries for the past 14
    days? ______Yes _____ No days? ______Yes _____ No
    If yes, please indicate the affected countries: _________ If yes, please indicate the affected countries: _________
    Signature (visitor): ______________Date: ______________ Signature (visitor): ______________Date: ______________
    *Note: Information captured is used for contact tracing if required *Note: Information captured is used for contact tracing if required
    Contact Tracing Tool for School-Goers Contact Tracing Tool for School-Goers

    NAME: CONTACT NUMBER: NAME: CONTACT NUMBER:


    HOME ADDRESS: TEMP: HOME ADDRESS: TEMP:
    SELF-DECLARATION BY VISITOR SELF-DECLARATION BY VISITOR
    1 If you have the following symptoms, please check the 1 If you have the following symptoms, please check the
    following; following;
    _____ Fever _____ Fever
    _____ Sore throat _____ Sore throat
    _____ Dry cough _____ Dry cough
    _____ Runny Nose _____ Runny Nose
    _____ Body Ache _____ Body Ache
    _____ Tiredness _____ Tiredness
    _____ Headache _____ Headache
    _____ Others _____ Others
    _____None _____None
    2 Have you been contact with confirmed COVID-19? 2 Have you been contact with confirmed COVID-19?
    ______Yes _____No ______Yes _____No
    3 Have you been to affected countries for the past 14 3 Have you been to affected countries for the past 14
    days? ______Yes _____ No days? ______Yes _____ No
    If yes, please indicate the affected countries: _________ If yes, please indicate the affected countries: _________
    Signature (visitor): ______________Date: ______________ Signature (visitor): ______________Date: ______________
    *Note: Information captured is used for contact tracing if required *Note: Information captured is used for contact tracing if required

    Contact Tracing Tool for School-Goers Contact Tracing Tool for School-Goers

    NAME: CONTACT NUMBER: NAME: CONTACT NUMBER:


    HOME ADDRESS: TEMP: HOME ADDRESS: TEMP:
    SELF-DECLARATION BY VISITOR SELF-DECLARATION BY VISITOR
    1 If you have the following symptoms, please check the 1 If you have the following symptoms, please check the
    following; following;
    _____ Fever _____ Fever
    _____ Sore throat _____ Sore throat
    _____ Dry cough _____ Dry cough
    _____ Runny Nose _____ Runny Nose
    _____ Body Ache _____ Body Ache
    _____ Tiredness _____ Tiredness
    _____ Headache _____ Headache
    _____ Others _____ Others
    _____None _____None
    2 Have you been contact with confirmed COVID-19? 2 Have you been contact with confirmed COVID-19?
    ______Yes _____No ______Yes _____No
    3 Have you been to affected countries for the past 14 3 Have you been to affected countries for the past 14
    days? ______Yes _____ No days? ______Yes _____ No
    If yes, please indicate the affected countries: _________ If yes, please indicate the affected countries: _________
    Signature (visitor): ______________Date: ______________ Signature (visitor): ______________Date: ______________
    *Note: Information captured is used for contact tracing if required *Note: Information captured is used for contact tracing if required

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