Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
CORNES, ANDRIE JOHN M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

 Republic of the Philippines
Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
DE LOS ANGELES, IAN M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

 Republic of the Philippines
Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
DELA CRUZ, FERNANDO M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

 Republic of the Philippines
Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
EDUARTE, CLOYD JUNNEL S. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

 Republic of the Philippines
Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
ESQUILONA, JHON CARLO M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.
 Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
GADO, JOHN RAYVEN M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.
 Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MAGADA, LORENZ D. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MAGADA, MARTIN M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MAGDATO, KAHLIL R. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MALAVEGA, CJ R. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
 nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MALAVEGA, LUIS M. II Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
 labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MERIDA, ANDREW MIGUEL R. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
 nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MOLLEDA, REY ALLEN S. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
 without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
RAMOS, JHAYVEE D. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
 araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
SALVANA, ARVIN F. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
 maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
SIERVO, RONMARK S. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
 10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
ABRIL, JANDY M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
1. Are you experiencing or a. Fever (Lagnat)
did you have any of the b. Cough and/or Colds (Ubo at/o Sipon)
following in the last 14 c. Body Pains (Pananakit ng katawan)
days? (Ikaw ba ay may d. Sore Throat (Pananakit o pamamaga ng lalamunan)
nararanasan o nakaranas e. Fatigue/Tiredness (Pagkapagod)
ng mga sumusunod na f. Headache (Pananakit ng Ulo)
sintomas sa nakaraang 14 g. Diarrhea (Pagtatae)
na araw?) h. Loss of taste or smell (Nawalan ng panlasa o pang-
amoy)
 i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
FALLARIA, YNA GRACE M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
1. Are you experiencing or a. Fever (Lagnat)
did you have any of the b. Cough and/or Colds (Ubo at/o Sipon)
following in the last 14 c. Body Pains (Pananakit ng katawan)
days? (Ikaw ba ay may d. Sore Throat (Pananakit o pamamaga ng lalamunan)
nararanasan o nakaranas e. Fatigue/Tiredness (Pagkapagod)
ng mga sumusunod na f. Headache (Pananakit ng Ulo)
sintomas sa nakaraang 14 g. Diarrhea (Pagtatae)
 h. Loss of taste or smell (Nawalan ng panlasa o pang-
amoy)
na araw?) i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
GALOS, GRECEL B. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
1. Are you experiencing or a. Fever (Lagnat)
did you have any of the b. Cough and/or Colds (Ubo at/o Sipon)
following in the last 14 c. Body Pains (Pananakit ng katawan)
days? (Ikaw ba ay may d. Sore Throat (Pananakit o pamamaga ng lalamunan)
nararanasan o nakaranas e. Fatigue/Tiredness (Pagkapagod)
 f. Headache (Pananakit ng Ulo)
g. Diarrhea (Pagtatae)
h. Loss of taste or smell (Nawalan ng panlasa o pang-
ng mga sumusunod na amoy)
sintomas sa nakaraang 14 i. Difficulty of breathing (Pagkahapo o hirap sa
na araw?) paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MAGADA, CHLOUE ANN R. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
1. Are you experiencing or a. Fever (Lagnat)
did you have any of the b. Cough and/or Colds (Ubo at/o Sipon)
following in the last 14 c. Body Pains (Pananakit ng katawan)
 d. Sore Throat (Pananakit o pamamaga ng lalamunan)
e. Fatigue/Tiredness (Pagkapagod)
f. Headache (Pananakit ng Ulo)
g. Diarrhea (Pagtatae)
days? (Ikaw ba ay may h. Loss of taste or smell (Nawalan ng panlasa o pang-
nararanasan o nakaranas amoy)
ng mga sumusunod na i. Difficulty of breathing (Pagkahapo o hirap sa
sintomas sa nakaraang 14 paghinga)
10. na araw?)
Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MAGDATO, ANGELA M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
1. Are you experiencing or a. Fever (Lagnat)
 b. Cough and/or Colds (Ubo at/o Sipon)
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
h. Loss of taste or smell (Nawalan ng panlasa o pang-
sintomas sa nakaraang 14
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MARQUEZ, IVY M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
 (Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MERIDA, MARY KEISHA F. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)
 Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
MONTON, ARIAN D. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
RABINO, CHARLOTTE S. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
 Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
 RIANO, NICOLE M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________

Republic of the Philippines

Department of Education
MIMAROPA Region
Division of Romblon
AGNIPA NATIONAL HIGH SCHOOL-EXTENSION
Romblon, Romblon

HEALTH DECLARATION FORM

 Full Name (Buong Pangalan): Date (Petsa) (MM/DD/YY): 08/22/2022
RUADO, GRAYSHELLE M. Time (Oras):
Complete Current Address (Kasalukuyang tirahan):
Mobile/Phone Number (Numero ng Telepono):
Email Address:
Put the check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)
a. Fever (Lagnat)
b. Cough and/or Colds (Ubo at/o Sipon)
1. Are you experiencing or
c. Body Pains (Pananakit ng katawan)
did you have any of the
d. Sore Throat (Pananakit o pamamaga ng lalamunan)
following in the last 14
e. Fatigue/Tiredness (Pagkapagod)
days? (Ikaw ba ay may
f. Headache (Pananakit ng Ulo)
nararanasan o nakaranas
g. Diarrhea (Pagtatae)
ng mga sumusunod na
sintomas sa nakaraang 14 h. Loss of taste or smell (Nawalan ng panlasa o pang-
na araw?) amoy)
i. Difficulty of breathing (Pagkahapo o hirap sa
paghinga)
10. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1
meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na
maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansiya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 na
araw?)
11. Have you provided direct care for a patient with probable or confirmed COVID-19 case
without using proper “Personal Protective Eaquipment (PPE)” for the past 14 days?
(Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi
nakasuot ng tamang PPE (Personal Protective Equipment) sa nakalipas na 14 araw?
12. Have you travelled outside the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa
labas ng Pilipinas sa nakalipas na 14 na araw?)
13. Have you travelled outside the current city/ municipality where you reside? (Ikaw ba ay
nagbiyahe sa labas ng iyong lungsod o munisipyo?) If yes, specify which city or
municipality you went to (Sabihin kung saan):__________________________________.

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the
date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda) : ______________________________________