LGU KALIBO COVID-19 ELECTRONIC IMMUNIZATION REGISTRY
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Email *
Resident Basic Information and Category
If the choices are not applicable, please choose or write "Others" or "NA"
CATEGORY *
SUB-CATEGORY
(Applicable for Health Care Worker only)
CATEGORY ID *
ID Number *
Philhealth ID *
PWD ID
Indicate N/A if not applicable
Last Name *
First Name *
Middle Name *
Suffix *
(JR, SR, I, II, III, etc.)
Contact Number *
09XXXXXXXXX
Street Name *
Region *
Province *
Municipality *
Barangay *
Sex *
Birthdate *
MM
/
DD
/
YYYY
Age *
Civil Status *
Employment Status *
Directly in interaction w/ COVID patient? *
Nakakasalamuha mo baea ro mga COVID patient?
Profession / Occupation *
Name of Employer *
Address of Employer *
Contact Number of Employer *
Medical History *
Check the following if applicable, if no known medical history check "None"
Required
Diagnosed with COVID 19 *
Date of first positive result
Skip if Not Applicable
MM
/
DD
/
YYYY
COVID 19 Classification
Skip if Not Applicable
Are you willing to be vaccinated? *
Nagasugot ka baea nga mabakunahan?
I confirm that the information I have given is true, correct and complete and that I understand failure to answer any question may have serious consequences under Philippines laws. (Article 171 and 172 of the Revised Penal Code of the Philippines) and  RA 9271 Quarantine Act of 2004.

We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law.
A copy of your responses will be emailed to the address you provided.
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