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Punit Elementary School Punit Elementary School: Health Declaration Form Health Declaration Form

This document is a health declaration form from Punit Elementary School. It requires a signature declaring that the signee and their household have not experienced any COVID-19 symptoms or been exposed to the virus in the past 14 days. Personal information is protected under Philippine data privacy laws and the form will be destroyed after 20 days.

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Beatriz Jean Calpito
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43 views1 page

Punit Elementary School Punit Elementary School: Health Declaration Form Health Declaration Form

This document is a health declaration form from Punit Elementary School. It requires a signature declaring that the signee and their household have not experienced any COVID-19 symptoms or been exposed to the virus in the past 14 days. Personal information is protected under Philippine data privacy laws and the form will be destroyed after 20 days.

Uploaded by

Beatriz Jean Calpito
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

Republic of the Philippines

Department of Education Republic of the Philippines


Region 02 (Cagayan Valley) De pa rtme nt of Educa tion
Schools Division Office of Isabela Region 02 (Cagayan Valley)
Benito Soliven North District Schools Division Office of Isabela
PUNIT ELEMENTARY SCHOOL Benito Soliven North District
Punit, Benito Soliven, Isabela PUNITELEMENTARYSCHOOL
0917-679-0815 *punitelementaryschool@gmail.com
Punit, Benito Soliven, Isabela
0917-679-0815 *punitelementaryschool@gmail.com
HEALTH DECLARATION FORM
HEALTH DECLARATION FORM
I, _______________________________, declare that my entire household was
not I, _______________________________, declare that my entire household was
considered a close contact, suspect, probable, or confirmed COVID-19 case within not
the past 14 days. Further, we do not experience any symptoms related to considered a close contact, suspect, probable, or confirmed COVID-19 case within
COVID-19 such as: the past 14 days. Further, we do not experience any symptoms related to
a. Fever COVID-19 such as:
b. Cough and colds a. Fever
c. Difficulty of breathing b. Cough and colds
d. Sore throat c. Difficulty of breathing
e. Diarrhea d. Sore throat
f. Fatigue/ Tiredness e. Diarrhea
g. Headache f. Fatigue/ Tiredness
h. Loss of taste or smell g. Headache
i. Body pains h. Loss of taste or smell
i. Body pains
I hereby certify that the information given is true, correct, and complete. I
understand that any falsified response may have serious consequences. I I hereby certify that the information given is true, correct, and complete. I
understand that my personal information is protected by RA 10173 or the Data understand that any falsified response may have serious consequences. I
Privacy Act of 2012 and that this form will be destroyed after 20 days from the understand that my personal information is protected by RA 10173 or the Data
date of accomplishment, following the National Archives of the Philippines Privacy Act of 2012 and that this form will be destroyed after 20 days from the
protocol. date of accomplishment, following the National Archives of the Philippines
protocol.

________________________________ __________________
Name and Signature Date ________________________________ __________________
Name and Signature Date

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