Health Check Declaration Form for Visitors
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Email *
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Date *
MM
/
DD
/
YYYY
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.
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