Republic of the Philippines

Department of Education
Schools Division OF NEGROS ORIENTAL
BINDOY DISTRICT II
Calatagan Elementary School
LEARNER’S HEALTH DECLARATION FORM
IMPORTANT REMINDER: The information collected on this form will be used to determine only whether you may be infected with
COVID-19. The information on this form will be maintained as confidential.
To prevent the spread and reduce the risk of exposure to COVID 19 in our school
and community, we would like to request your cooperation by kindly accomplishing the health
survey form below. Your truthful participation is important to help in instituting precautionary
measures in the workplace. Any information that you have provided will be handled according to
the Privacy Act and will only be used if contact tracing is necessary. Thank you for your time.

NAME: School: Calatagan Elementary School

Grade Level/ Section attended: Address:
AGE: GENDER:
MOBILE NO.: TEMPERATURE:

1. Self-Declaration
1. [ ] No Symptoms [ ] With Symptoms
2. [ ] No Comorbidity [ ] With Comorbidity
3. [ ] Vaccinated ___1st Dose ___2nd Dose ____Booster [ ] Not Vaccinated
2. Please put a check mark if you have any of the symptoms below the past 14
days:
[ ] Fever [ ] Dry cough [ ] Body weakness [ ] Headache [ ] Runny nose [ ]
Tiredness
[ ] Sore Throat [ ] Shortness of Breath [ ] Severe Diarrhea [ ] Loss of Smell/Taste
3. Have you been in contact with any COVID-19 confirmed positive patient in the
14 days?
[ ] Yes [ ] No
4. Travel history: [ ] Yes [ ] No
If yes, Date of Departure: ___________ Arrival Date: _____________
Places visited within the past (2) weeks: _____________________

Signature: __________________ Date: _______________

Noted by: FLOURAMIE A. PACUNLA
Class Adviser
Verifier: CARLA MARIE C. SARABIA
Clinic Teacher/SBFP Coordinator
 Republic of the Philippines
Department of Education
Schools Division OF NEGROS ORIENTAL
BINDOY DISTRICT II
Calatagan Elementary School
LEARNER’S CONTACT TRACING SHEET
Grade III-FALCON
SY 2021-2022

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