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Health Declaration Card: Republic of The Philippines Province of Aklan

This health declaration card collects personal information from tourists entering the province of Aklan, Philippines. It informs that the data will only be used for COVID-19 contact tracing. The card collects the traveler's name, nationality, birthdate, arrival date, contact details, passport information, places visited in the last 30 days, health status, and requires an electronic signature agreeing to share information and confirming the truth of the details provided, with legal consequences for providing false information. It will be reviewed and signed by a Quarantine Medical Officer upon submission.

Uploaded by

Christina Quiachon
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
478 views

Health Declaration Card: Republic of The Philippines Province of Aklan

This health declaration card collects personal information from tourists entering the province of Aklan, Philippines. It informs that the data will only be used for COVID-19 contact tracing. The card collects the traveler's name, nationality, birthdate, arrival date, contact details, passport information, places visited in the last 30 days, health status, and requires an electronic signature agreeing to share information and confirming the truth of the details provided, with legal consequences for providing false information. It will be reviewed and signed by a Quarantine Medical Officer upon submission.

Uploaded by

Christina Quiachon
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD


Tourists

-- Please read before proceeding --


In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you
will be providing in this form shall not be used for other purposes except for COVID-19 contact-
tracing activities. Control no. 539c513c-5806-441c-9725-d2123cf90828

Email [email protected] Mobile/Contact No: 09398435187


Passport No/Valid ID Type & No NA
First Name Middle Name Last Name
Name MA CHRISTINA LACHICA QUIACHON
[ ]
Nationality FILIPINO Sex [ ] Male
Female
Birthdate (mm Arrival Date (mm
-dd-yyyy) 04-21-2000 -dd-yyyy) 12-19-2020
Passenger Type [ ] Passenger [ ] Crew
Seat
Flight/Bus Number/Vessel Name na na
No.
Name of Hotel/Place of stay IN
AKLAN
CROWN REGENCY BEACH RESORT
Street No. and Name of Street ( If applicable, indicate name of barangay)
1949 ACEVEDO STREET
Municipality/City:
Residence
KALIBO
Address Province:
(Philippines) AKLAN
Region:
VI
Country(ies) worked, visited and transited in the last 30 days.
NA

Have you been sick in the past 30 days? [ ] Yes [ ] No


Upon submitting, I am providing consent to sharing my information for
contact tracing purposes, I confirm that the information I have given is
true, correct and complete and that I understand failure to answer any
question may have serious consequences under Philippines laws. (Article
171 and 172 of the Revised Penal Code of the Philippines) Signature of Passenger/Crew
Notation by the QMO:

Signed:

Name and signature of QMO-on-Duty


Date and Time

Aklan Border Control Management App 2020 ; Maintained by APICTO - 12/4/2020 1:01:57 AM

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