MEYCAUAYAN COLLEGE

GRADUATE STUDIES

HEALTH DECLARATION FORM

F2F Comprehensive Examination

June 25, 2022

To: GS Compre Examinees, Examiners and All Others Concerned;

To prevent the spread of COVID 19 in our community and reduce the risk of exposure, we would like
to request your cooperation by kindly accomplishing the Health Declaration Form below. Your participation is
important to help in instituting precautionary measures in the workplace. Any information that you have
provided will be handled according to the Data Privacy Act and will only be used if contact tracing is
necessary. Data shall be kept with utmost confidentiality. Thank you.

NAME: JANMOR M. SAPUNGAN ADDRESS: TALA CALOOCAN

MOBILE NO.:09760114300 BODY TEMPERATURE: 36.1

AGE: 40
GENDER:MALE

Kindly check under the YES and NO Column for your answer.
YES NO
a.Sore Throat
(Pananakit ng lalamunan)
b. Body Pain
1. Are you
(Pananakit ng Katawan)
experiencing
c. Headache
:
(Pananakit ng Ulo)
d. Fever for the past few days
(Lagnat sa nakalipas na mga araw)
2. Have you worked together or stayed in the same close environment or a
confirmed COVID-19 case?
(May nakasama o nakatrabahong tao na kumpirmadong may COVID-19 o may
impeksyon ng corona virus)
3. Have you had contact with anyone with fever, cough, colds and sore throat for the
past 14 Days?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID 19?)
4. Have you travelled to any area with positive COVID-19 case?
(Ikaw ba ay nakapunta sa lugar na amay kumpirmadong kaso ng COVID-19?)
5. Have you ever travelled outside the Philippines in the last 14 days?
(Ikaw ba ay nakabiyahe sa labas ng Bansa sa nakalipas na 14 na araw?
Certification and Data Privacy Consent
I certify that the above-mentioned information I provided is true, correct and complete, I hereby authorize the
Graduate School Department of Meycauayan College, Inc. to collect and process the information indicated
herein, in accordance with applicable laws and regulations, for the purpose of affecting control of the COVID-19
infection.

JANMOR SAPUNGAN
 MEYCAUAYAN COLLEGE
GRADUATE STUDIES
Name and Signature of Declarant
Date Signed: 6/20/2022