PSC-MSAS Covid-19 Health Declaration Form (HDF) for Guests,  Visitors, Athletes, Coaches, NSA Staff
Kindly fill out the  HDF and click to submit for our records. This is being done to help control the spread of Covid-19. Your HONEST and ACCURATE responses to the items will be your contribution in our  fight against COVID-19.
Be assured that your replies will be treated with confidentiality.

Thank you for your cooperation.

We Heal As One!

PSC-MSAS
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Email *
Please select if you are: *
Required
For Athletes/Coach, write down your Sport:
PERSONAL  INFORMATION
Contact details are important in case of possible Contact Tracing.
Name *
Age (last birthday) *
PSC Office you are visiting *
Cellphone number *
ADDRESS where you reside/stay  in the last 30 days (include barangay name and/or number) *
HEALTH-RELATED INFORMATION
In the last 14 days, I experienced Flu-like symptoms ("trangkaso"). *
If you answered YES, check the symptom/s you have experienced.
In the last 14 days, there was more than one (1)  case who experienced the above-named symptom/s in my area of residence/barangay. *
If Yes, give the name/street of barangay where there was more than one (1) case.
In the last 14 days, I traveled to other areas aside from my place of residence/barangay. *
If Yes, Where and When you traveled outside your place of residence.
In the last 14 days, I had close contact* with person/s who came in from outside the Philippines. *(with more than 15 mins cumulative exposure) *
If Yes, when was your contact?
MM
/
DD
/
YYYY
In the last 14 days, I had close contact* with diagnosed COVID19 positive patient/s *(with more than 2 hrs. exposure) *
If Yes, When and Where was your contact with a positive COVID 19 patient?
AUTHORIZATION
I hereby authorize the Philippine Sports Commission to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 disease. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

I certify that the above declarations in the Health Declaration Form are accurate and true.

****END****



A copy of your responses will be emailed to the address you provided.
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