Republic of the Philippines Republic of the Philippines
Department of Education Department of Education
MIMAROPA REGION MIMAROPA REGION
SCHOOLS DIVISION OF ORIENTAL MINDORO SCHOOLS DIVISION OF ORIENTAL MINDORO
PUERTO GALERA NATIONAL HIGH SCHOOL PUERTO GALERA NATIONAL HIGH SCHOOL
HEALTH DECLARATION FORM HEALTH DECLARATION FORM
Temperature: ______________ Temperature: ______________
I, ____________________________________________, declare I, ____________________________________________, declare
that my entire household was not considered a close contact, that my entire household was not considered a close contact,
suspect, probable, or confirmed COVID-19 case the past 14 days. suspect, probable, or confirmed COVID-19 case the past 14 days.
Further, we do not experience any symptoms related to COVID- Further, we do not experience any symptoms related to COVID-
19 such as: 19 such as:
a. Fever e. Fatigue/Tiredness a. Fever e. Fatigue/Tiredness
b. Cough and colds f. Headache b. Cough and colds f. Headache
c. Difficulty of breathing g. Loss of taste or smell c. Difficulty of breathing g. Loss of taste or smell
d. Sore throat h. Body pains d. Sore throat h. Body pains
I hereby certify that the information given is true, correct and I hereby certify that the information given is true, correct and
complete, I understand that any falsified response may have complete, I understand that any falsified response may have
series consequences. I understand that my personal information series consequences. I understand that my personal information
is protected by RA 10173 or the Data Privacy Act of 2012and that is protected by RA 10173 or the Data Privacy Act of 2012and that
this form will be destroyed after 20 days from the date of this form will be destroyed after 20 days from the date of
accomplishment, following the National Archives of the accomplishment, following the National Archives of the
Philippines protocol. Philippines protocol.
_________________________________ _____________________ _________________________________ _____________________
Signature over Printed Name Date Signature over Printed Name Date
Address: _____________________________________ Sex: M / F Address: _____________________________________ Sex: M / F
Contact no.: __________________________ Age: ________ Contact no.: __________________________ Age: ________
Republic of the Philippines Republic of the Philippines
Department of Education Department of Education
MIMAROPA REGION MIMAROPA REGION
SCHOOLS DIVISION OF ORIENTAL MINDORO SCHOOLS DIVISION OF ORIENTAL MINDORO
PUERTO GALERA NATIONAL HIGH SCHOOL PUERTO GALERA NATIONAL HIGH SCHOOL
HEALTH DECLARATION FORM HEALTH DECLARATION FORM
Temperature: ______________ Temperature: ______________
I, ____________________________________________, declare I, ____________________________________________, declare
that my entire household was not considered a close contact, that my entire household was not considered a close contact,
suspect, probable, or confirmed COVID-19 case the past 14 days. suspect, probable, or confirmed COVID-19 case the past 14 days.
Further, we do not experience any symptoms related to COVID- Further, we do not experience any symptoms related to COVID-
19 such as: 19 such as:
a. Fever e. Fatigue/Tiredness a. Fever e. Fatigue/Tiredness
b. Cough and colds f. Headache b. Cough and colds f. Headache
c. Difficulty of breathing g. Loss of taste or smell c. Difficulty of breathing g. Loss of taste or smell
d. Sore throat h. Body pains d. Sore throat h. Body pains
I hereby certify that the information given is true, correct and I hereby certify that the information given is true, correct and
complete, I understand that any falsified response may have complete, I understand that any falsified response may have
series consequences. I understand that my personal information series consequences. I understand that my personal information
is protected by RA 10173 or the Data Privacy Act of 2012and that is protected by RA 10173 or the Data Privacy Act of 2012and that
this form will be destroyed after 20 days from the date of this form will be destroyed after 20 days from the date of
accomplishment, following the National Archives of the accomplishment, following the National Archives of the
Philippines protocol. Philippines protocol.
_________________________________ _____________________ _________________________________ _____________________
Signature over Printed Name Date Signature over Printed Name Date
Address: _____________________________________ Sex: M / F Address: _____________________________________ Sex: M / F
Contact no.: __________________________ Age: ________ Contact no.: __________________________ Age: ________
