Republic of the Philippines

Department of Education

BUGUEY SOUTH CENTRAL SCHOOL

HEALTH DECLARATION FORM

To prevent the spread of COVID-19 and reduce the risk of exposure among the
participants of this year’s Division Schools Press Conference, this health
declaration form should be accomplished.

Name:

Age: Sex:

Home Address:

CP#

Venue: PENABLANCA NATIONAL HIGH SCHOOL

Purpose: TO ATTEND DIVISION JOURNALYMPICS

Temperature Reading: Date: Time:

1. In the past 14 days, which of the following symptom/s have you

experienced? Please check relevant boxes:
Yes No
Fever Dry Cough
Sore Throat Tiredness
Diarrhea Shortness of breath
Body Aches Runny
Headache Others: NONE OF THE ABOVE

2. Have you been in contact with a confirmed COVID-19 patient in the

past 14 days?
Yes No

3. Have you been residing in areas identified as high-risk of COVID-

19? Yes No
If yes, please specify the area: ___________________________________.
Declaration and Data Privacy Consent Form:

The information I have given are true, correct, and complete. I understand
that failure to answer any question or giving false answer can be penalized
in accordance with existing laws.

I voluntarily and freely consent to the collection and sharing of the above
personal information for the purpose stated herein.

____________________________ _____________
Signature over Printed Name Date