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Health-Declaration-Form 2021 educ
Course: Physical Fitness and Health (PE 1)
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Republic of the Philippines
Department of Education
Region X-Northern Mindanao
SCHOOLS DIVISION OF ILIGAN CITY
_________________________________________________________
_______________________________________________________________________________________
Address: Gen. Aguinaldo St., Iligan City
Telefax No.: (063) 221-6069
iligan.city@deped.gov.ph
Office of the Schools Division Superintendent
HEALTH DECLARATION FORM
Name of Examinee:
Home Address:
Contact Number:
School Testing Center:
Date and Time of the Exam:
Yes
No
1
Are you experiencing
a.
Sore throat
b.
Body pains
c.
Headache
d
Fever for the past few days
2
Have you worked together or stayed in the same close environment
of a confirmed COVID-19 case?
3
Have you had any contact with anyone with fever, cough, colds and
sore throat in the past 2 weeks?
4
Have you travelled outside of the Philippines in the last 14 days?
5
Have you travelled to any area in Region 10 aside from your home?
6
For Female Examinee: Are you pregnant?
7
Do you have any comorbidities, immunodeficiency or other health
risk?
I hereby authorized Deped Iligan City to collect and process the data indicated herein for the
purpose of effecting control of the COVID-19 infection. I understand that any personal
information is protected by RA 10173 "Data Privacy Act of 2012" and that I am required by RA
11409 "Bayanihan to Heal as one Act" to provide truthful information.
Signature Over Printed Name