SACRED HEART DE ILOILO
Felix Gorriceta Avenue, Balabag, Pavia, Iloilo
HEALTH DECLARATION FORM
Dear Parents & Students,
We would like to ensure everyone’s safety during and after you visit the venue (Iloilo Gateway
Hotel) for our End-of-School year rites. Please answer all the questions appropriately and
honestly.
Date:
Time:
Name: _______________
Last Name
Grade & Section:
Gender:
Age:
Male
Female
Body Temperature:
___________________________
First Name
Status:
Single
Widow
____________
Middle Initial
Contact No:
Married
Seperated
Complete Address:
Please place a check mark under your response.
YES
NO
YES
NO
1. Are you
experiencing
the
following?
a) fever
e) Headache
b) Cough &
f) Body
colds
pain/muscle pain
c) Sore throat
g) Diarrhea
d) Difficulty of
breathing
2. Have you had face-to-face contact with a probable or confirmed
COVID-19 case within 1 meter and and for more than 15 minutes for
the past 14 days?
3. Have you provided direct care for a patient with probable or
confirmed COVID-19 case without using proper personal protective
equipment for the past 14 days?
4. Have you travelled outside the Phillipines in the last 14 days?
5. Have you travelled outside in the current city/municipality where
you reside If yes, which citymunicipality you went to:
6. Are you residing or working to areas with high incidence of COVID19 cases? If yes which place are you residing or workplace:
7. Have you been tested for COVID-19?
I hereby authorize Sacred Heart De Iloilo to collect and process the data indicated herein for
the purpose of effecting control of the COVID-19 infection. I understand that my personal
information is protected by RA 10173 or the Data Privacy Act of 2012, and that I am required
by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. And that this form
will be destroyed after 30 days from the date of accomplishement following the National
Archives of the Philippines protocol. Furthermore, I am aware that any false or wrong
information I may have provided herein would warrant the filing of criminal case against me
such as, but not limited to perjury as provided for by Article 172 of the Revised Penal Code of
the Philippines.
Signature: ___________________________