Form B1: Donor Intent Form (Individual)
Please complete this form if you are interested in becoming a donor for COVID-19 response. Personal information submitted will be used only for communication and monitoring purposes. Rest assured that it will be treated with utmost confidentiality.

In compliance with Administrative Order No. 27, s. 2020, we strongly encourage donors of medicines, medical equipment and supplies, and other health products to address COVID-19, whether given to the National Government as a whole or to the Department of Health (DOH) to inform the Office of Civil Defense (OCD) directly for inventory purposes and to help the Government ensure equitable allocation and distribution of assistance.

(Maaaring sagutan ang form na ito kung ikaw ay interesadong maging donor para sa COVID-19 response. Makakasiguro ka na iingatan at gagamitin lamang namin ang iyong personal na impormasyon para sa pakikipag-ugnayan at monitoring.

Bilang pagsunod sa Administrative Order No. 27, s. 2020, hinihikayat namin ang mga nagbigay ng donasyong gamot, kagamitang medikal, at iba pang produktong pangkalusugan para sa pagtugon sa COVID-19 sa national government o Department of Health na ipagbigay alam sa Office of Civil Defense (OCD) para maitala at masiguro ang tamang alokasyon at distribusyon.)
GENERAL INSTRUCTIONS
Please answer N/A if the question is not applicable. If you would like to provide additional information which cannot be captured by the questions, please include these under the " Additional Information" which can be found near the end of this form.

(Maaaring sumagot ng "N/A" kung hindi naaangkop ang tanong. Kung nais mong magbigay ng karagdagang impormasyon na hindi saklaw ng tanong sa bahaging ito, maari mong ilagay ang mga ito sa " Karagdagang Impormasyon" na matatagpuan malapit sa dulo ng form na ito.)
Personal Information
Last Name (Apelyido) *
First Name (Unang Pangalan) *
Middle Name (Gitnang Pangalan)
Age (Edad) *
Sex (Kasarian) *
Government Issued ID and Number
Complete Address (House No., Street, Subdivision, Barangay, City/Municipality, Province)
House/Unit/Block/Lot No. *
Street/Subdivision *
Barangay *
City/Municipality *
Province (If you are from NCR, please answer N/A)
Region *
E-mail Address *
Mobile/Telephone Number *
Facebook URL/username, if any
For other social media accounts, please provide username, if any
Occupation ( Trabaho) *
If others, please specify... (Kung iba pa, tukuyin...)
Type of Donation
I want to Donate: *
Required
If goods, please specify... (Kung gamit, tukuyin)
If money, please specify how much (Kung pera, tukuyin kung magkano)
Source/s of Funds of Donation
If others, please specify... (Kung iba, tukuyin)
Preferred Direct Recipient of Donation (Organisayon/Grupo kung saan nais magbigay ng donasyon) *
Required
If others, please specify...
Please specify the name of the preferred organization/individual chosen as direct recipient of donation (Tukuyin ang pangalan ng organisasyon o indibidwal na pinili o nais ibigay ang donasyon)
In case your target recipient institution does not like to accept donations, are you willing to be referred to other institutions? (Kung ang institusyon na gustong pagbigyan ay hindi nais tumanggap ng donasyon, ikaw ba ay bukas na magbigay sa ibang imumungkahi na institusyon?) *
Additional information regarding your donation (Karagdagang impormasyon tungkol sa donasyon)
Thank you for answering this form.
Later on, we will ask you to accomplish a report form where you can provide information on the donation you have given.
Submit
Never submit passwords through Google Forms.
This form was created inside of PNVSCA. Report Abuse