Republic of the Philippines

Department of Education
REGION V (BICOL)
SCHOOLS DIVISION OF CATANDUANES
CALATAGAN HIGH SCHOOL
Virac, Catanduanes

HEALTH DECLARATION FORM TEMPERATURE: _____________

NAME: _________________________________________________SEX: _________ AGE: _________

ADDRESS: _________________________________________________________________________
HOUSE NO. PUROK NO/STREET BARANGAY MUNICIPALITY PROVINCE
DEPARTMENT/GRADE AND SECTION: ____________________CONTACT NUMBER: _____________

Answer the questions HONESTLY. Place a check mark on the cell corresponding your answer.
QUESTIONS/ MGA KATANUNGAN YES NO
1. Are you experiencing: Nakakaranas ka ba ng:
a. Sore throat (pananakit ng lalamunan/masakit lumunok)
b. Body pains (pananakit ng katawan)
c. Headache (pananakit ng ulo)
d. Fever for the past few days (lagnat sa mga nakalipas na araw)
2. Have you worked together or stayed on the same close environment of a
confirmed COVID-19 case? (May nakasama kaba o nakatrabanong tao na
kumpirmadong may COV1D-19 o may impeksyon ng Corona Virus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat
the past 2 weeks? (Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng
lalamanan sa nakalipas na dalawang (2) linggo?)
4. Have you travelled outside the Catanduanes in the last 14 days? (Ikaw ba ay
bumiyahe sa labas ng Catanduanes sa nakalipas na 14 na araw?)
5. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay
bumiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)

I hereby authorize CHS Health Coordinators to collect and process the data herein for the purpose
of effecting control of the Covid-19 infection. I understand that my personal information is
protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to
Heal as One Act, to provide truthful Iformation.

______________________________
Signature over Printed Name
Date Signed:__________________

CALATAGAN HIGH SCHOOL

Address: Calatagan,Virac,Catanduanes
School ID: 302084
E-mail Address: 302084@deped.gov.ph