CNU Health Declaration Form

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In compliance with IATF regulations, all personnel and external clients of the University are required to fill out contact tracing and health declaration forms. The University reserves the right to refuse entry into its premises any person who fails or refuses to accomplish and submit this form, and who it reasonably deems may pose a risk to other people.

Email address *

Date Today *

YYYY

Name (Family Name, First Name, MI) *

Age *

Gender *

Male

Female

Prefer not say

Other

Date of Scheduled Appointment *

YYYY

Office of Transaction *

Mobile Number *

Do you have any flu-like symptoms? If yes, tick all that apply. If no, tick none. *

None

Fever

Cough

Colds

Headache

Sore throat

Difficulty breathing

Body pains

Required

Declaration *

Data Privacy Statement. I agree that all foregoing information will be used by Cebu Normal University for purposes of containing and controlling the occurrence of infectious diseases within the CNU campus and for the purpose of contact tracing and monitoring. Further, no item in this questionnaire shall be used by CNU other than its intended purpose. All information provided are true, correct, and complete. File copy at CNU Medical Services Office.

Required

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