NAME: Strong, Sylvia Goñi

CONTACT NUMBER: 09173015626

DATE OF TRAVEL: 21/06/2021

DESTINATION: Lot 8 Block 3 Mars St., Puentevella Subd., Brgy. Taculing,

Taculing

BaCTrac ID No.: 06800190183326

Are you experiencing fever? No

Are you experiencing cough and/or colds? No

Are you experiencing body pains? No

Are you experiencing sore throat? No

Are you experiencing loss of sense of smell? No

Are you experiencing LBM? No

Are you experiencing loss of sense of taste? No

Are you experiencing a headache? No

Are you experiencing difficulty breathing? No

Have you had face to face contact with a probable or confirmed No

COVID-19 case within 1 meter or for more than 15 minutes in
the past 14 days?

Have you provided direct care for a patient with a probable or No

confirmed COVID-19 case without proper PPE in the past 14
days?

Have you travelled outside the current city/ municipality where No

you reside? (If yes please specify.)

Which city or municipality?

Have you travelled outside of the Philippines in the last 14 days? No

(If yes please specify.)

Which country abroad?