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    ISO Health Checklist

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    Ronnel Saludez
    This document is a health declaration form from the Nueva Vizcaya State University in the Philippines. The form collects information such as name, temperature, reason for visit, travel history, and symptoms from employees, students, visitors and others entering the university. It asks if the individual has traveled internationally, been in contact with COVID-19 patients, or lives with someone who has. It authorizes the university to collect and process this health data to control COVID-19 infection, in accordance with relevant privacy and health laws. The form must be filled out truthfully and noted by a medical officer.

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

    ISO Health Checklist

    Uploaded by

    Ronnel Saludez
    16 views1 page
    This document is a health declaration form from the Nueva Vizcaya State University in the Philippines. The form collects information such as name, temperature, reason for visit, travel history, and symptoms from employees, students, visitors and others entering the university. It asks if the individual has traveled internationally, been in contact with COVID-19 patients, or lives with someone who has. It authorizes the university to collect and process this health data to control COVID-19 infection, in accordance with relevant privacy and health laws. The form must be filled out truthfully and noted by a medical officer.

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    ISO-Health-Checklist

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    This document is a health declaration form from the Nueva Vizcaya State University in the Philippines. The form collects information such as name, temperature, reason for visit, travel history, and symptoms from employees, students, visitors and others entering the university. It asks if the individual has traveled internationally, been in contact with COVID-19 patients, or lives with someone who has. It authorizes the university to collect and process this health data to control COVID-19 infection, in accordance with relevant privacy and health laws. The form must be filled out truthfully and noted by a medical officer.

    Copyright:

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

    ISO Health Checklist

    Uploaded by

    Ronnel Saludez
    This document is a health declaration form from the Nueva Vizcaya State University in the Philippines. The form collects information such as name, temperature, reason for visit, travel history, and symptoms from employees, students, visitors and others entering the university. It asks if the individual has traveled internationally, been in contact with COVID-19 patients, or lives with someone who has. It authorizes the university to collect and process this health data to control COVID-19 infection, in accordance with relevant privacy and health laws. The form must be filled out truthfully and noted by a medical officer.

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    © All Rights Reserved
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    Republic of the Philippines Republic of the Philippines

    NUEVA VIZCAYA STATE UNIVERSITY NUEVA VIZCAYA STATE UNIVERSITY


    Bayombong, Nueva Vizcaya Bayombong, Nueva Vizcaya
    HEALTH DECLARATION FORM HEALTH DECLARATION FORM
    HDF No.:____________________________ HDF No.:___________________________

    Employee Student Visitors Others: _______________________ Employee Student Visitors Others: _______________________
    Please complete the following details: Please complete the following details:
    NAME: Temperature: NAME: Temperature:
    Nature of Visit: ___ Official ___ Personal Contact No: Nature of Visit: ___ Official ___ Personal Contact No:
    Office to Visit: Office to Visit:
    Company/Agency/Address: Company/Agency/Address:

    Please answer the following questions truthfully. YES NO Please answer the following questions truthfully. YES NO
    1. Have you travelled outside the Philippines or outside the province 1. Have you travelled outside the Philippines or outside the province
    including NCR in the last 14 days? including NCR in the last 14 days?
    If yes, give details: _________________________________________ If yes, give details: ________________________________________
    2. Are you experiencing: 2. Are you experiencing:
    a. sore throat a. sore throat
    b. body pains b. body pains
    b. headache c. headache
    c. fever in the past few days d. fever in the past few days
    d. Difficulty of breathing e. Difficulty of breathing
    e. Cough and/or colds f. Cough and/or colds
    3. Have you had any contact with anyone with fever, cough, colds, and 3. Have you had any contact with anyone with fever, cough, colds, and
    sore throat in the past 14 days? sore throat in the past 14 days?
    4. Have you worked together, stayed in the same close environment with, 4. Have you worked together, stayed in the same close environment
    or physically encountered a confirmed COVID-19 case? with, or physically encountered a confirmed COVID-19 case?
    5. Do you have anyone living in your household who came from NCR or 5. Do you have anyone living in your household who came from NCR
    any COVID-19 saturated places or from abroad? or any COVID-19 saturated places or from abroad?
    If yes, give details: _________________________________________ If yes, give details: _______________________________________

    I hereby authorize Nueva Vizcaya State University to collect and process the data I hereby authorize Nueva Vizcaya State University to collect and process the data
    indicated herein for the purpose of effecting the control of COVID-19 infection. I understand that indicated herein for the purpose of effecting the control of COVID-19 infection. I understand
    my personal information is protected by RA No. 10173 or the Data Privacy Act of 2012, and that that my personal information is protected by RA No. 10173 or the Data Privacy Act of 2012, and
    I am required by RA No. 11469 or the Bayanihan to Heal As One Act, to provide truthful that I am required by RA No. 11469 or the Bayanihan to Heal As One Act, to provide truthful
    information. information.

    Signature: ________________________________ Date: _____________________ Signature: ________________________________ Date: _____________________

    Noted by: KRISTIAN DANIELLE R. PASCUAL-FERNANDEZ, MD Noted by: KRISTIAN DANIELLE R. PASCUAL-FERNANDEZ, MD
    Medical Officer III Medical Officer III

    NVSU-FR-MED-06-00 (112521) NVSU-FR-MED-06-00 (112521)

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