you reside?

(Ikaw ba ay nagbiyahe sa labas ng inyong

lungsod/munisipyo?) If yes, specify which city/municipality you
went to (Sabihin kung saan) :
________________________________________

I herby certify that the information given is true, correct and complete. I understand that failure to answer
any question or any falsified response may have serious consecquences. 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 acccomplishment, following the National Archives of the Philippines protocol.
Annex D Signature (Lagda): __________________________________
HEALTH DECLARATION FORM Source: COMELEC (Note: Ask DOH of the standard delacration form, and appropraite action per reported
information (e.g., do not allow entry if they checked “yes” to any statement?), if available.)
Full Name ( Buong Pangalan) Date (Pesta) (MM/DD/YY) :
Time (Oras):
a. Fever (Lagnat) Yes No
(Oo) (Hindi)
b. Cough and/ or Colds (Ubo at/ o Sipon)
c. Body pains (Pananakit ng katawan) Annex D
HEALTH DECLARATION FORM
d. Soar Throath (Pananakit or Pamamaga ng Full Name ( Buong Pangalan) Date (Pesta) (MM/DD/YY) :
lalamunan) Time (Oras):
e. Fatigue/Tirediness (Pagkapagod) a. Fever (Lagnat) Yes No
f. Headache (Pananakit ng ulo) (Oo) (Hindi)
b. Cough and/ or Colds (Ubo at/ o Sipon)
g. Diarrhea ( Pagtatae)
c. Body pains (Pananakit ng katawan)
h. Loss of taste or smell (Nawalan ng panlasa
or pang-amoy) d. Soar Throath (Pananakit or Pamamaga ng
i.Difficulty of breathing (Pagkahapo o hirap lalamunan)
sa paghinga) e. Fatigue/Tirediness (Pagkapagod)
2. Have to had face to face contact with a probable or confirmed f. Headache (Pananakit ng ulo)
COVID-19 case within ! meter and for more than 15 minutes for the
past 14 days? (May nakasalamuha ka ba na maaaring o g. Diarrhea ( Pagtatae)
kumpirmadong pasyente na may COVID-19 mula sa isang metrong
h. Loss of taste or smell (Nawalan ng panlasa
distansya or mas malapit pa at tumagal ng mahigit 15 minuto sa
or pang-amoy)
nakalipas na 14 araw?)
i.Difficulty of breathing (Pagkahapo o hirap
3. Have you provided direct care for a patient with probable or
sa paghinga)
confirmed COVID-19 case without using proper “Personal
Protective Equipment (PPE)” for the past 14 days? (Nag alaga ka ba 2. Have to had face to face contact with a probable or confirmed
ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi COVID-19 case within ! meter and for more than 15 minutes for the
nkasuot ng tamang PPE (Peersonal Protective Equipment) sa past 14 days? (May nakasalamuha ka ba na maaaring o
nakalipas na 14 araw?) kumpirmadong pasyente na may COVID-19 mula sa isang metrong
distansya or mas malapit pa at tumagal ng mahigit 15 minuto sa
4. Have you traveled outside the Philippines in the last 14 days?
nakalipas na 14 araw?)
(Ikaw ba ay ngbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?)
3. Have you provided direct care for a patient with probable or
5. Have you traveled outside the current city/municipality where
confirmed COVID-19 case without using proper “Personal
you reside? (Ikaw ba ay nagbiyahe sa labas ng inyong
Protective Equipment (PPE)” for the past 14 days? (Nag alaga ka ba
lungsod/munisipyo?) If yes, specify which city/municipality you
ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi
went to (Sabihin kung saan) :
nkasuot ng tamang PPE (Peersonal Protective Equipment) sa
________________________________________
nakalipas na 14 araw?)
4. Have you traveled outside the Philippines in the last 14 days?
I herby certify that the information given is true, correct and complete. I understand that failure to answer (Ikaw ba ay ngbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?)
any question or any falsified response may have serious consecquences. I understand that my personal 5. Have you traveled outside the current city/municipality where
information is protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed
you reside? (Ikaw ba ay nagbiyahe sa labas ng inyong
after 20 days from the date of acccomplishment, following the National Archives of the Philippines protocol.
lungsod/munisipyo?) If yes, specify which city/municipality you
went to (Sabihin kung saan) :
Signature (Lagda): __________________________________ ________________________________________
Source: COMELEC (Note: Ask DOH of the standard delacration form, and appropraite action per reported
information (e.g., do not allow entry if they checked “yes” to any statement?), if available.
I herby certify that the information given is true, correct and complete. I understand that failure to answer
any question or any falsified response may have serious consecquences. I understand that my personal
Annex D information is protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed
HEALTH DECLARATION FORM after 20 days from the date of acccomplishment, following the National Archives of the Philippines protocol.
Full Name ( Buong Pangalan) Date (Pesta) (MM/DD/YY) :
Time (Oras): Signature (Lagda): __________________________________
a. Fever (Lagnat) Yes No Source: COMELEC (Note: Ask DOH of the standard delacration form, and appropraite action per reported
(Oo) (Hindi) information (e.g., do not allow entry if they checked “yes” to any statement?), if available.)
b. Cough and/ or Colds (Ubo at/ o Sipon)

c. Body pains (Pananakit ng katawan) Annex D

HEALTH DECLARATION FORM
d. Soar Throath (Pananakit or Pamamaga ng Full Name ( Buong Pangalan) Date (Pesta) (MM/DD/YY) :
lalamunan) Time (Oras):
e. Fatigue/Tirediness (Pagkapagod) a. Fever (Lagnat) Yes No
(Oo) (Hindi)
f. Headache (Pananakit ng ulo)
b. Cough and/ or Colds (Ubo at/ o Sipon)
g. Diarrhea ( Pagtatae)
c. Body pains (Pananakit ng katawan)
h. Loss of taste or smell (Nawalan ng panlasa
d. Soar Throath (Pananakit or Pamamaga ng
or pang-amoy)
lalamunan)
i.Difficulty of breathing (Pagkahapo o hirap
e. Fatigue/Tirediness (Pagkapagod)
sa paghinga)
2. Have to had face to face contact with a probable or confirmed f. Headache (Pananakit ng ulo)
COVID-19 case within ! meter and for more than 15 minutes for the
past 14 days? (May nakasalamuha ka ba na maaaring o g. Diarrhea ( Pagtatae)
kumpirmadong pasyente na may COVID-19 mula sa isang metrong
h. Loss of taste or smell (Nawalan ng panlasa
distansya or mas malapit pa at tumagal ng mahigit 15 minuto sa
or pang-amoy)
nakalipas na 14 araw?)
i.Difficulty of breathing (Pagkahapo o hirap
3. Have you provided direct care for a patient with probable or
sa paghinga)
confirmed COVID-19 case without using proper “Personal
2. Have to had face to face contact with a probable or confirmed
Protective Equipment (PPE)” for the past 14 days? (Nag alaga ka ba
COVID-19 case within ! meter and for more than 15 minutes for the
ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi
past 14 days? (May nakasalamuha ka ba na maaaring o
nkasuot ng tamang PPE (Peersonal Protective Equipment) sa
kumpirmadong pasyente na may COVID-19 mula sa isang metrong
nakalipas na 14 araw?)
distansya or mas malapit pa at tumagal ng mahigit 15 minuto sa
4. Have you traveled outside the Philippines in the last 14 days?
nakalipas na 14 araw?)
(Ikaw ba ay ngbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?)
3. Have you provided direct care for a patient with probable or
5. Have you traveled outside the current city/municipality where
confirmed COVID-19 case without using proper “Personal
 Protective Equipment (PPE)” for the past 14 days? (Nag alaga ka ba
ng maaring o kumpirmadong pasyente na may COVID-19 ng hindi
nkasuot ng tamang PPE (Peersonal Protective Equipment) sa
nakalipas na 14 araw?)
4. Have you traveled outside the Philippines in the last 14 days?
(Ikaw ba ay ngbiyahe sa labas ng Pilipinas sa nakalipas na 14 araw?)
5. Have you traveled outside the current city/municipality where
you reside? (Ikaw ba ay nagbiyahe sa labas ng inyong
lungsod/munisipyo?) If yes, specify which city/municipality you
went to (Sabihin kung saan) :
________________________________________

I herby certify that the information given is true, correct and complete. I understand that
failure to answer any question or any falsified response may have serious consecquences. 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 acccomplishment, following the National Archives of the
Philippines protocol.
Signature (Lagda): __________________________________
Source: COMELEC (Note: Ask DOH of the standard delacration form, and appropraite action per reported
information (e.g., do not allow entry if they checked “yes” to any statement?), if available.)