Health Check Declaration Form for Visitors
Sign in to Google to save your progress. Learn more
Email *
Clear selection
Date *
Name *
Temperature(Degree Celsius) *
Sex *
Age *
Residence *
Contact Number *
Are you experiencing any of the following?
(Nakaranas kaba nang alinman sa mga sumusunod?)
Fever for the past few days (Lagnat sa nka lipas na mga araw) *
Dry Cough (Tuyong ubo) *
Fatigue (Pagkapagod) *
Aches and Pains (Pananakit nang katawan) *
Runny Nose (Sipon) *
Shortness of Breath (Hirap sa paghinga) *
Diarhea (Pagtatae) *
Loss of taste and/or smell *
2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 Case or a suspected COVID CASE? *
3. Have you had any contact with anyone with fever, cough, colds and sore throat in the past 2weeks? *
4. Have you travelled or visited a friend relatives in a COVID 19 infected place for the last 14 days? *
Have you travelled to any part of Cebu City aside from your home; if YES pls specify in the "Other.." option below. *
I hereby authorize the Department of Science and Technology to collect and process the data indicated herein for purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by 10173, Data Privacy Act of 2012, and I am required by RA 11469, Bayanihan to Heal as One Act, to provide truth information.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy