Scribd
Upload
21 views1 page

Department of Education: Republic of The Philippines

Uploaded by

Nhatz Gallosa Marticio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
21 views1 page

Department of Education: Republic of The Philippines

Uploaded by

Nhatz Gallosa Marticio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
You are on page 1/ 1

Republic of the Philippines

Department of Education
REGION III- CENTRAL LUZON
SCHOOLS DIVISION OF ZAMBALES
HEALTH DECLARATION FORM
Have exposure to Have travel
Check the ff. symptoms you have in the suspected or history outside
past 14 days? confirmed COVID-19 the province in
case for the past 14 the past 14 days:
Date Time Name Age Sex Address Contact Number days:
Temp. Fever Cough Colds Shortness Difficulty Sore If yes, what is No If yes, No
of Breath of Throa your
Breathin t where?
g
relationship to
the patient:

Address: Zone VI, Iba, Zambales


Telephone No: (047) 602 1391
Email Address: [email protected]
Page 1 of 1

You might also like