Title Health Declaration Form_2022-05 revised (A5).pdf ✅

(Revised, May 2022) HEALTH DECLARATION Body Temperature: ___________________ (Instruction to leave blank as temp will be supplied on the day of exam after scanning) Date: ________________________ Full Name: _____________________________ Sex: ______ Age: ______ Residence: _____________________________________________________ Contact Number/s: _______________________________________________ Are you currently experiencing symptoms, or have experienced, within the last 14 days: (Kasalukuyan ka bang nakakaranas ng sintomas o nakaranas sa huling 14 na araw) Symptoms (Mga sintomas) YES (Oo) NO (Hindi) a. Sore throat (Pananakit ng lalamunan/masakit lumunok) b. Shortness of Breath (Hirap sa paghinga) c. Body pains (Pananakit ng katawan) d. Headache (Pananakit ng ulo) e. Fever for the past few days (Lagnat sa mga nakalipas na araw) f. Loss of taste or smell (Pagkawala ng panlasa o pang-amoy) g. Cough and/or cold (Ubo at/o sipon) h. Diarrhea (Pagtatae) I declare under oath that I personally accomplished this Health Declaration form. Further, I declare that the information given are true, correct, and complete statements pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of the Philippines. I hereby authorize the CIVIL SERVICE COMMISSION (CSC), to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA No. 11469, Bayanihan to Heal as One Act, as amended by RA 11494, to provide truthful information. Further, I understand that any false information may have serious public health implications and may be subjected to legal consequences. Finally, I understand that, in case I would test positive for COVID-19 within 14 days after the exam day, the CSC shall, upon request of the LGU/Barangay concerned, provide my necessary/pertinent information for contact tracing. Signature: __________________________________