PICC Health Declaration Form
All information will be treated in confidentiality and will only be used for contact tracing, should the need arise.
Full Name (buong pangalan) *
Complete Current Address (kasalukuyang tirahan) *
Mobile/Phone Number (Numero ng telepono) *
Email address *
What among the following have you experienced in the last 14 days? (Anu-ano sa mga ito ang iyong naramdaman sa nakalipas na 14 araw?) *choose all that apply (piliin lahat ng nag-aapply) *
Required
Were you exposed to a probable or confirmed COVID-19 case within 1 meter and for more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na maaaring o kumpirmadong pasyente na may COVID-19 mula sa isang metrong distansya o mas malapit pa at tumagal ng mahigit 15 minuto sa nakalipas na 14 araw?) *
Have you provided direct care for a patient with probable or confirmed COVID-19 case without using proper "Personal Protective Equipment (PPE)" for the past 14 days? (Nag-alaga ka ba ng maaaring o kumpirmadong pasyente na may COVID-19 ng hindi nakasuot ng "Personal Protective Equipment (PPE)" sa nakalipas na 14 araw?)
Clear selection
Have you traveled outside the Philippines in the last 14 days? (Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 araw?) *
Have you traveled outside the current municipality where you reside? (Ikaw ba ay nagbyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify which city/municipality you went to (sabihin kung saan) *
I hereby certify that the information given is true, correct and complete. I understand that failure to answer any question or any falsified response may have serious consequences. I understand that my personal information is protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the date of accomplishment, following the National Archives of the Philippines protocol. Do you agree (sumasang-ayon ka ba)? *
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