Republic of the Philippines Republic of the Philippines

Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGIONAL OFFICE 9
BFL Building, Fernan St., Purok San Pedro, Pagadian City
Mobile Number: 09499969882
Email: commel9one@gmail.com
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGIONAL OFFICE 9
BFL Building, Fernan St., Purok San Pedro, Pagadian City
Mobile Number: 09499969882
Email: commel9one@gmail.com

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

NAME: AGE: NAME: AGE:

CONTACT NUMBER: TEMP: CONTACT NUMBER: TEMP:
ADDRESS: ADDRESS:

HAVE YOU BEEN IN CONTACT WITH PEOPLE BEING INFECTED, HAVE YOU BEEN IN CONTACT WITH PEOPLE BEING INFECTED,
SUSPECTED OR DIAGNOSED WITH COVID-19? IF YES, DATE OF SUSPECTED OR DIAGNOSED WITH COVID-19? IF YES, DATE OF
CONTACT CONTACT

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT OR PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT OR
DURING THE PAST 14 DAYS: DURING THE PAST 14 DAYS:
FEVER COUGH FEVER COUGH
HEADACHE DIFFICULTY OF BREATHING HEADACHE DIFFICULTY OF BREATHING
SORE THROAT UNEXPLAINED BRUISING/BLEEDING SORE THROAT UNEXPLAINED BRUISING/BLEEDING
BODY WEAKNESS DIARRHEA BODY WEAKNESS DIARRHEA
OTHERS: OTHERS:

I ACKNOWLEDGE THAT THE INFORMATION I’VE GIVEN IS I ACKNOWLEDGE THAT THE INFORMATION I’VE GIVEN IS
ACCURATE AND COMPLETE ACCURATE AND COMPLETE

SIGNATURE DATE SIGNATURE DATE

Republic of the Philippines Republic of the Philippines

Department of the Interior and Local Government Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION BUREAU OF FIRE PROTECTION
REGIONAL OFFICE 9 REGIONAL OFFICE 9
BFL Building, Fernan St., Purok San Pedro, Pagadian City BFL Building, Fernan St., Purok San Pedro, Pagadian City
Mobile Number: 09499969882 Mobile Number: 09499969882
Email: commel9one@gmail.com Email: commel9one@gmail.com

HEALTH DECLARATION FORM HEALTH DECLARATION FORM

NAME: AGE: NAME: AGE:

CONTACT NUMBER: TEMP: CONTACT NUMBER: TEMP:
ADDRESS: ADDRESS:

HAVE YOU BEEN IN CONTACT WITH PEOPLE BEING INFECTED, HAVE YOU BEEN IN CONTACT WITH PEOPLE BEING INFECTED,
SUSPECTED OR DIAGNOSED WITH COVID-19? IF YES, DATE OF SUSPECTED OR DIAGNOSED WITH COVID-19? IF YES, DATE OF
CONTACT CONTACT

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT OR PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING AT OR
DURING THE PAST 14 DAYS: DURING THE PAST 14 DAYS:
FEVER COUGH FEVER COUGH
HEADACHE DIFFICULTY OF BREATHING HEADACHE DIFFICULTY OF BREATHING
SORE THROAT UNEXPLAINED BRUISING/BLEEDING SORE THROAT UNEXPLAINED BRUISING/BLEEDING
BODY WEAKNESS DIARRHEA BODY WEAKNESS DIARRHEA
OTHERS: OTHERS:

I ACKNOWLEDGE THAT THE INFORMATION I’VE GIVEN IS I ACKNOWLEDGE THAT THE INFORMATION I’VE GIVEN IS
ACCURATE AND COMPLETE ACCURATE AND COMPLETE

___ _______________
SIGNATURE DATE SIGNATURE DATE