REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF AGRARIAN REFORM FULL NAME: ___________

Tunay na Pagbabago sa Repormang Agraryo POSITION APPLYING: ___

COVID-19 TIME AND DATE OF EXAM

CONTACT TRACING / HEALTH DECLARATION FORM VENUE OF EXAM: ______
FILL OUT ENTRIES IN BOLD LETTERS DATE:

Personal Data: EXAMINEE NUMBER: ___

Name: ______________________________________________________________________
Last Name First Name Middle Name
Sex: [ ] Female [ ] Male Age: _______
Contact Address: _____________________________________________________________
Mobile No/ Telephone No.: __________________ E-mail Address: ______________________
Temperature (Upon Entry): __________
Please check if you have any of the following at present or during the past 14 days:
[ ] Cough [ ] Diarrhea
[ ] Headache [ ] Fatigue [ ] Nausea/Vomiting
[ ] Sore Throat [ ] Body Aches [ ] Body Weakness
[ ] Difficulty/Shortness of Breath [ ] Loss of Taste or Smell [ ] Runny Nose
Have you travelled to or from countries/areas of concern within 14 days? If YES, provide details.
______________________________________________________________
Have you been in close contact with a person with a confirmed case of COVID-19 within 14 days? YES [ ] NO [ ]
Have you undergone any test for SARS-Cov2 for the past 14 days? YES [ ] NO [ ]
Where was the test done? ___________________ Date of Release: ___________________

Note: IF YES PLEASE PROVIDE A COPY OF THE RESULT

FOR THE PURPOSES OF PUBLIC WELFARE AND SAFTEY, I HEREBY CONSENT FOR THE AFOREMENTIONED
INFORMATION TO BE PROVIDED TO GOVERNMENT HEALTH AUTHORITIES AT ANY MOMENT IT IS REQUIRED

SIGNATURE: ______________________ DATE: _______________________

DAR REGIONAL OFFICE VIII Tel. No. (053)325-3096
Sto. Niño Extension, Tacloban City Website: www.dar.gov.ph
 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF AGRARIAN REFORM
Tunay na Pagbabago sa Repormang Agraryo

DAR REGIONAL OFFICE VIII Tel. No. (053)325-3096

Sto. Niño Extension, Tacloban City Website: www.dar.gov.ph