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    F2F HAF For Student

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    G4 AMOYO ANGELICA NICOLE
    The student health assessment form summarizes Angelica Nicole Amoyo's health status. She is an 18 year old female nursing student at Our Lady of Fatima University. She answered no to all questions regarding COVID-19 symptoms or exposure in the past 14 days. The form states the school's policy that students may not attend campus if they have COVID-19 symptoms or exposure and must follow quarantine protocols before returning. Angelica affirmed the truth of her responses and consented to the school collecting her health data to control COVID-19 spread.

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    F2F HAF For Student

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    G4 AMOYO ANGELICA NICOLE
    26 views1 page
    The student health assessment form summarizes Angelica Nicole Amoyo's health status. She is an 18 year old female nursing student at Our Lady of Fatima University. She answered no to all questions regarding COVID-19 symptoms or exposure in the past 14 days. The form states the school's policy that students may not attend campus if they have COVID-19 symptoms or exposure and must follow quarantine protocols before returning. Angelica affirmed the truth of her responses and consented to the school collecting her health data to control COVID-19 spread.

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    F2F HAF for Student

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    The student health assessment form summarizes Angelica Nicole Amoyo's health status. She is an 18 year old female nursing student at Our Lady of Fatima University. She answered no to all questions regarding COVID-19 symptoms or exposure in the past 14 days. The form states the school's policy that students may not attend campus if they have COVID-19 symptoms or exposure and must follow quarantine protocols before returning. Angelica affirmed the truth of her responses and consented to the school collecting her health data to control COVID-19 spread.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    26 views1 page

    F2F HAF For Student

    Uploaded by

    G4 AMOYO ANGELICA NICOLE
    The student health assessment form summarizes Angelica Nicole Amoyo's health status. She is an 18 year old female nursing student at Our Lady of Fatima University. She answered no to all questions regarding COVID-19 symptoms or exposure in the past 14 days. The form states the school's policy that students may not attend campus if they have COVID-19 symptoms or exposure and must follow quarantine protocols before returning. Angelica affirmed the truth of her responses and consented to the school collecting her health data to control COVID-19 spread.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 1

    STUDENT’S HEALTH ASSESSMENT FORM

    HWC 044-20-22

    Name AMOYO, ANGELICA NICOLE Campus Valenzuela


    Age 18 Gender FEMALE Contact Numbers 09434659776 Year/Section 1 YC 7 College/Strand NURSING

    Mark with a check (✓) your answer to the following questions: YES NO
    1. Have you experienced any of the following in the past 14 days
    Sore Throat /
    Body Pain /
    Headache /
    Fever /
    Cough /
    Colds /
    Difficulty of breathing /
    Diarrhea /
    Nausea/Vomiting /
    Tiredness /
    Loss of Taste and Smell /
    Skin Rash /
    Red Eyes /
    Loss of Movement and Speech /
    Chest Pain or Pressure /
    2. Have you worked together or stayed in the same close environment with a confirmed
    COVID-19 case or PUI under self-quarantine in your house or in your neighborhood? /
    2. Did you have any contact with anyone with fever, cough, colds, and sore throat in the
    past 14 days? /
    4. Have you travelled outside of the Philippines in the last 14 days? /
    5. Do you have any of the following conditions: /
    60 years old and above
    On-going pregnancy
    Hypertension
    Heart disease
    Diabetes mellitus
    Recurrent asthma attacks
    Chronic lung disease- ongoing PTB treatment
    COPD
    Cancer
    Blood dyscrasias
    Chronic liver and kidney diseases
    Currently undergoing dialysis treatment
    Immunocompromised status
    Autoimmune disease
    Other Illnesses

    I fully understand that it is the policy of the Our Lady of Fatima University that no students regardless of status shall be
    allowed to report for school on campus if any of the abovementioned conditions are present. A student may only report
    back to school after following the 14-day quarantine protocol and submit a medical clearance/fit to school
    certificate from the School Physician before reporting on campus.
    For senior citizens: I fully understand that I must follow the prevailing guidelines prescribed by the COVID-19
    Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).
    I attest that all the information given above are true and correct and that I may be held liable for any misinformation
    stated herein. I also authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose
    of effecting the control of COVID-19 infection and that my personal information are protected by RA.10173 (Data Privacy
    Act of 2012) and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.

    Student’s Signature Over Printed Name:


    ANGELICA NICOLE AMOYO
    Full Name Here Date: 6/26/22

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