Republic of the Philippines
Department of Education
HEALTH DECLARATION FORM
To prevent the spread of COVID-19 and reduce the risk of exposure among the
participants of this year’s Congressional Eliminations in Campus Journalism, this
health declaration form should be accomplished.
Name:
Age:
Sex:
Home Address:
Contact Number:
Venue:
Purpose:
Temperature Reading:
Date:
Time:
1. In the past 14 days, which of the following symptom/s have you
experienced? Please check relevant boxes:
Fever
Dry Cough
Sore Throat
Tiredness
Diarrhea
Shortness of breath
Body Aches
Runny Nose
Headache
Others: _________________________
NONE OF THE ABOVE
2. Have you been in contact with a confirmed COVID-19 patient in the past
14 days?
Yes
No
3. Have you been residing in areas identified as high-risk of COVID-19?
Yes
No
If yes, please specify the area: ___________________________________.
Declaration and Data Privacy Consent Form:
The information I have given are true, correct, and complete. I understand that
failure to answer any question or giving false answer can be penalized in
accordance with existing laws.
I voluntarily and freely consent to the collection and sharing of the above personal
information for the purpose stated herein.
_______________________________
Signature over Printed Name
__________________________
Date