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Health Declaration Form: Applicant Profile

This document is a health declaration form from the Commission on Elections in Baguio City, Philippines. It collects personal information such as name, birthdate, contact details, occupation, travel history, exposure history, and current health status from applicants. Applicants are asked if they have traveled to countries with COVID-19, been exposed to confirmed cases, exhibited symptoms, and are currently suffering from flu-like symptoms. They must declare that all information provided is true and correct.

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Onyx Xyno
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137 views1 page

Health Declaration Form: Applicant Profile

This document is a health declaration form from the Commission on Elections in Baguio City, Philippines. It collects personal information such as name, birthdate, contact details, occupation, travel history, exposure history, and current health status from applicants. Applicants are asked if they have traveled to countries with COVID-19, been exposed to confirmed cases, exhibited symptoms, and are currently suffering from flu-like symptoms. They must declare that all information provided is true and correct.

Uploaded by

Onyx Xyno
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

COMMISSION ON ELECTIONS
Office of the Election Officer
Baguio City

HEALTH DECLARATION FORM


APPLICANT PROFILE
Name:
(Last Name, First Name, Middle Name)
Birthday : Age: Sex: ( ) Male
(mm/dd/yyyy) ( ) Female
Occupation: Civil Status: Nationality:

PHILIPPINE RESIDENCE
Address:
( House No./Lot/Bldg., Street, Barangay, Municipality/City, Province )
Tel. No.: Cellphone No.: Email add.:

Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence outside the Philippines

Employer's Name: Occupation: Place of Work:


Address:
( House No./Lot/Bldg., Street, Barangay, Municipality/City, Province, Country )
Office Phone No: Cellphone No.:
TRAVEL HISTORY

History of travel/visit/work in other countries with a known COVID-19 transmission: ( ) Yes ( ) No

Port (Country of Exit): Airline/Sea Vessel:


Flight/Vessel No.: Date of Departure: Date of Arrival (Phils.)
EXPOSURE HISTORY
History of Exposure to known ( ) Yes If yes: Date of contact with known COVID-
COVID-19 to case ( ) No 19 CASE: (mm/dd/yyyy)
( ) Unknown
Have you been in a place with a ( ) Yes If yes: ( ) Work Place
known COVID-19 transmission: ( ) No (Place) ( ) Social gathering
( ) Unknown ( ) Health facility
( ) Religious gathering
( ) Others: specify type: ____________________
If Yes: Date when you have been in that place: Name of the Place: _______________
(mm/dd/yyyy)

Name Contact Number


List the names of persons who were with you during this/these
1
occasion(s) and their contact numbers:
2
(Use back part of this sheet when neccessary)
3
Are you a confirmed case of COVID-19 (Coronavirus). ( ) Yes ( ) No

Are you suffering from any of the following flu-like symptoms (or in the last 48 hours), which may
include: Fever, Cough, Sore-throat, Running nose or Stuffy nose, Headache, Aches and pains, ( ) Yes ( ) No
Fatigue, Breathing difficulty, or any other symptoms (i.e. gastroenteritis related or similar)

I declare that all the information given in this form is true and correct:

(Date) (Signature over Printed Name of Applicant)

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