Scribd Logo
Upload

Welcome to Scribd!

  • 39 views

    Health Declaration Form

    Uploaded by

    kimbeerlyn doromas

    Copyright:

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

    Health Declaration Form

    Uploaded by

    kimbeerlyn doromas
    39 views1 page

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    39 views1 page

    Health Declaration Form

    Uploaded by

    kimbeerlyn doromas

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    of 1
    BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM Date: Body Temperature Name Dose ‘Grade ana Secon Ci Fatyaceinatea ‘Age:_Sex:___ Contact Number: Ey uae ithaay. aadress [ae yeu oxpenereng Seve Taal? BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM at Body Temperatur Name: Ly #tdeee Grade and Section: C1 Fatly Vaccinated Age:__ Sex:__ Contact Number: as Binthday. Clem aadress Are you openerenng Sore Tic re you expensing bo pai? re you expensing bo pai? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? [ave you raveled any areain Regan Xl aside fom your toms? [ave you raveled any areain Regan Xl aside fom your toms? ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM ate: Body Temperatu Name: Ly #tdeee Grade and Section: C1 Fatly Vaccinated ‘Contact Number Li emacc ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed BONIFACIO R. TAGABAN SR. INTEGRATED SCHOOL HEALTH DECLARATION FORM ate: Body Temperatur Name: Ly #tdeee Grade and Section: C1 Fatly Vaccinated Age:__ Sex:__ Contact Number: as = C umaccinated aadress [ae yeu oxpenereng Seve Taal? Are you openereng Sa Ti re you expensing bo pai? re you expensing bo pai? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [Wve you expereneing headache? Are you experiencing fee: er the past ow ays? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? [ave you work iogter or stayed he sae cose enurenent of confirmed OOVID.19 cate? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? ‘| ave you ac ny contact wih anyone wi ever, eaigh 5 2nd 91 throat in the paat Wo} weeks? [Have you raves cus te Phlppines ve ast 14 days? [ave you raveled any areain Regan Xl aside fom your toms? [ave you raveled any areain Regan Xl aside fom your toms? ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed ‘hereby authored Oop nto Tapban Sr intepated Schoal collect an process he tinct hon fo te purpes of eectig cone Be COVID-T ito, ungestan hat mypersoral formations protect by A 10173 Dat Privacy At of 2092 and] ‘am required by RA M148, Byannan to Hel as One Act provi ut infomaton ‘Signature Over Pred ane Die Signed

    You might also like