Scribd
Upload
28 views3 pages

Annex B (Health Declaration Checklist)

Uploaded by

miraycabahug
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
28 views3 pages

Annex B (Health Declaration Checklist)

Uploaded by

miraycabahug
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Annex “B”

HEALTH DECLARATION CHECKLIST

IMPORTANT REMINDER: The information collected on this form will be used to determine only whether you
may be infected with COVID-19. The information on this form will be maintained as confidential.

FILL OUT ENTRIES IN BOLD LETTERS

Personal Data:

Name:
Last Name First Name Middle Name
Sex: [ ] Female Age:
[ ] Male
Contact Address:
(HOUSE NO. & STREET) (BARANGAY) (TOWN/DISTRICT)

(CITY/PROVINCE) (COUNTRY/STATE) (POSTAL/ZIP CODE)

Mobile No/ Telephone No.: Email Address:


Place of Work:
(If applicable)

Please check if you have any of the following at present or during the past 14 days:
[ ] Fever ≥ 37.50C (oral temperature) [ ] Cough [ ] Diarrhea
[ ] Headache [ ] Fatigue [ ] Nausea/Vomiting
[ ] Sore Throat [ ] Body Aches [ ] Body Weakness
[ ] Difficulty or [ ] Loss of Taste or Smell [ ] Runny
Nose Shortness of Breath

Please enumerate, if any, cities in the Philippines you have worked, lived, transited in the
past 14 days.

Please enumerate, if any, foreign countries you have worked, lived, transited in the past
14 days.
Please check the appropriate box
YES NO
Did you visit any health worker, hospital, or clinic during the past [] [ ]
14 days?
Were you confined in a hospital or clinic during the past 14 days? [] [ ]
Do you have anyone such as household member/s or close [ ] [ ]
contact/s who are currently having fever, cough and/or
respiratory problems?

In the last 14 days, have you been in close contact or exposed to [] [ ]


any
person suspected of COVID-19?
Have you been in Face-to-face contact with a confirmed case within[ ] []
1 meter and for more than 15 minutes?
In the last 14 days, have you been in contact with a person confirmed [
] [ ] with
COVID-19?
When did this person or contact receive a positive RT-PCR test?

Have you undergone any test for SARS-Cov2 for the past 14 days? [ ] []
Test Type: RT-PCR Rapid Serology Antibody
Test
Cartridge-based PCR Rapid Antigen Test
Rapid ECLIA Antibody Test Others, specify:
Results: Positive Negative Reactive Non-reactive
Sample Unfit for Testing Pending

Where was the test done? Date of Release:

Note:
IF DONE, THE ORIGINAL OFFICIAL RESULT OF RT-PCR SHOULD BE ATTACHED TO
THIS FORM. IN LIEU OF THE RT-PCR, A CERTIFICATE OF QUARANTINE OR ITS
EQUIVALENT SIGNED BY LICENSED PHYSICIAN (GOVERNMENT OR PRIVATE
PHYSICIAN) OR DULY AUTHORIZED LOCAL OFFICIAL SHOULD BE
ATTACHED/SUBMITTED.
DECLARATION AND
DATA PRIVACY CONSENT FORM

I submit that the information I have given is true, correct, and complete. I understand that my failure to answer

Name and Signature Date

shall only be used in relation to the aforementioned protocols in accordance with the Data Privacy Act and Mandatory Reporting of Notifiable Diseases and

Verified by (PRC Representative/Proctor):

Signature above Printed


Name

You might also like