CLIENT/ VISITORS HEALTH DECLARATION FORM
Name:
Date of Visit:
Address:
Time of Visit:
Phone #:
Email Address:
Purpose:
School/ District:
Temperature:
YES
NO
Are you experiencing a. Fever
b. Cough or colds
c. Body pains
d. Sore throat
Have you had face to face contact with a probable or confirmed COVID-19 case within 1
meter for more than 15 minutes for the past 14 days?
Have you provided direct care for a patient with probable or confirmed case COVID -19 care
without proper protective equipment for the past 14 days?
Have you travelled outside the Philippines in the last 14 days? ________________________
Have you travelled outside the current city, municipality where you reside?
__________________
I declare that the information I gave are true and that I am liable to the laws of the land if information given
are inaccurate.
I hereby authorize DEPED SURIGAO DEL NORTE, to collect and process data indicated herein for the purpose of
contact tracing effecting control of the COVID-19 transmission. 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 30 days from
the data accomplishment, following the National Archives of the Philippine Protocol.
_____________________________
Name and Signature
CLIENT/ VISITORS HEALTH DECLARATION FORM
Name:
Date of Visit:
Address:
Time of Visit:
Phone #:
Email Address:
Purpose:
School/ District:
Temperature:
YES
NO
Are you experiencing a. Fever
b. Cough or colds
c. Body pains
d. Sore throat
Have you had face to face contact with a probable or confirmed COVID-19 case within 1
meter for more than 15 minutes for the past 14 days?
Have you provided direct care for a patient with probable or confirmed case COVID -19 care
without proper protective equipment for the past 14 days?
Have you travelled outside the Philippines in the last 14 days?
Have you travelled outside the current city, municipality where you reside?
I declare that the information I gave are accurate and that I am liable to the laws of the land if information
given are false.
I hereby authorize DEPED SURIGAO DEL NORTE, to collect and process data indicated herein for the purpose of
contact tracing effecting control of the COVID-19 transmission. 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 30 days from
the data accomplishment, following the National Archives of the Philippine Protocol.
_____________________________
Name and Signature