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    Visitors Personal Declaration Form - COVID 19

    Uploaded by

    Leoni Franc
    This document is a travel and health declaration form filled out by Crystal M. De Jesus for a meeting at STI on June 27, 2021. She declares that in the last 14 days she has not traveled outside the Philippines, is not under quarantine, and has not been in contact with any confirmed COVID-19 cases. She also does not have any COVID-19 symptoms. The form requires contact details and travel history to assess exposure risk to COVID-19 for personnel, client, and public safety.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Visitors Personal Declaration Form - COVID 19

    Uploaded by

    Leoni Franc
    43 views1 page
    This document is a travel and health declaration form filled out by Crystal M. De Jesus for a meeting at STI on June 27, 2021. She declares that in the last 14 days she has not traveled outside the Philippines, is not under quarantine, and has not been in contact with any confirmed COVID-19 cases. She also does not have any COVID-19 symptoms. The form requires contact details and travel history to assess exposure risk to COVID-19 for personnel, client, and public safety.

    Original Title

    Visitors-Personal-Declaration-Form_COVID-19

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    This document is a travel and health declaration form filled out by Crystal M. De Jesus for a meeting at STI on June 27, 2021. She declares that in the last 14 days she has not traveled outside the Philippines, is not under quarantine, and has not been in contact with any confirmed COVID-19 cases. She also does not have any COVID-19 symptoms. The form requires contact details and travel history to assess exposure risk to COVID-19 for personnel, client, and public safety.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    43 views1 page

    Visitors Personal Declaration Form - COVID 19

    Uploaded by

    Leoni Franc
    This document is a travel and health declaration form filled out by Crystal M. De Jesus for a meeting at STI on June 27, 2021. She declares that in the last 14 days she has not traveled outside the Philippines, is not under quarantine, and has not been in contact with any confirmed COVID-19 cases. She also does not have any COVID-19 symptoms. The form requires contact details and travel history to assess exposure risk to COVID-19 for personnel, client, and public safety.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    As part of the precautionary measures against COVID-19 and for the interest of the well-being of our

    personnel, clients, visitors and the general public safety, we require you to fill-out declaration of your travel and health status.

    PERSONAL INFORMATION
    Full Name: Contact Number:
    CRYSTAL M. DE JESUS 09277370707
    Organization’s Name and Address
    281 MAHOGANY ST. KALAWAAN PASIG CITY

    TRAVEL DECLARATION AND VISIT INFORMATION


    Please state the cities that you have visited in the 14 days prior this meeting/event and the dates of your travel.
    Date of Entry Date of Exit
    City (If outside the Philippines, include also in the list below)
    (dd/mm/yyyy): (dd/mm/yyyy):
    1
    2
    Date of Visit
    Name(s) of STI staff and/or client that you are meeting with: Time of Visit
    (dd/mm/yyyy)
    4:00 PM -5:00
    MR. WILDREDO URIARTE 06/27/2021
    PM
    OTHER DECLARATION
    Please tick the box for each item YES NO
    1 You or any member of your household / roommate have returned from
    foreign/local travel in the fourteen (14) days prior to this date ☐ ☒
    2 You or any of member of your household / roommate are currently under a
    ☐ ☒
    quarantine order
    3 You have been in close contact with a confirmed case of COVID-19 in the
    ☐ ☒
    fourteen (14) days prior to this day
    4 You are experiencing any of the following symptoms:
    ☐ ☒
    a. Temperature of 37.6 degrees Celsius or higher
    b. Cough and runny nose ☐ ☒
    c. Sore throat ☐ ☒
    d. Shortness of breath ☐ ☒
    e. Headaches ☐ ☒
    f. Gastrointestinal upset ☐ ☒
    g. Lethargy/fatigue/tiredness/body aches ☐ ☒

    ____________________________________________
    Signature over printed name

    PRIVACY NOTICE
    In line with STI’s compliance with Data Privacy Act, any information declared in this form will be used solely for
    evaluation on possible exposure to COVID-19.

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