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Health Dec. Form PDF

This health declaration form collects information from visitors such as name, address, purpose of visit, and travel history. It asks if the individual has experienced COVID-19 symptoms like sore throat, body pains, or fever in recent days. It also asks if the person has been in contact with confirmed COVID-19 cases or others exhibiting symptoms, or has traveled outside the Philippines or other areas of NCR in the last two weeks. By signing, the individual authorizes the collection of this data for COVID-19 screening and acknowledges their requirement to provide truthful information under relevant laws.

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Lli Ocampo
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72 views1 page

Health Dec. Form PDF

This health declaration form collects information from visitors such as name, address, purpose of visit, and travel history. It asks if the individual has experienced COVID-19 symptoms like sore throat, body pains, or fever in recent days. It also asks if the person has been in contact with confirmed COVID-19 cases or others exhibiting symptoms, or has traveled outside the Philippines or other areas of NCR in the last two weeks. By signing, the individual authorizes the collection of this data for COVID-19 screening and acknowledges their requirement to provide truthful information under relevant laws.

Uploaded by

Lli Ocampo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Health and Travel History Declaration Form Temperature:

Name: _______________________________________ Sex: ______Age: ___________


Residence: ___________________________________________________________________
Nature of Visit: Official:
Please check one Personal: If official, fill-in company details below
Company Name : ______________________________________________________________
Company
Address: ____________________________________________________________________
1. Are you experiencing: Yes No
(nakakaranas ka ba ng:) a. Sore throat
(pananakit ng lalamunan / masakit
lumunok)
b. Body pains
(panankit ng katawan)
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 of a
confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao na
kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)
3. Have oyu had any contact with anyone with fever, cough, cold, and sore throat in
the past 2 weeks? (mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit
ng lalamunan sa nakalipas na dalawang (2) lingo?)
4. Have you travelled outside of the Philippines in the last 14 days?
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
5. Have you travelled to any area in NCR aside from your home? (Ikaw ba ay
nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong bahay?)
Specify (Sabihin kung saan):_____________________

I hereby authorize Wind Residences Condominium Corporation, to collect and process the data indicated
herein for the purpose of effecting control of COVID-19 inspection. 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 information.

Signature: _______________________________________ Date: __________________

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