Batangas City COVID-19 Survey Form
Batangas City's Vaccination Program for COVID-19
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Informed Consent
In compliance with the requirements of the Republic Act 10173 also known as Data Privacy Act of 2012, we would like to secure your consent on the general use and processing of information obtained from you in the course of this survey. Your response will be completely anonymous. Thank you.
Last Name *
First Name *
Middle Name *
Sex *
Address *
Pakiusap: Lehitimong mga taga-Batangas City po lamang
Barangay *
Pakiusap: Lehitimong mga taga-Batangas City po lamang
Birthday *
MM
/
DD
/
YYYY
Phone Number *
E-mail Address *
Informed Consent *
Required
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