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Health Status Declaration Form
I hereby acknowledge that the information is true and complete. I understand that my failure to answer, or any false or misleading information given by me may be used as ground for filing a case against me under Articles 171 and 172 of the Revised Penal Code of the Philippines or Republic Act Number 11332, otherwise known as the Law on Reporting of Communicable Disease.
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Indicates required field
Date Accomplished
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Name
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First
Last
Age
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Email
*
Phone Number
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Address
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Are you experiencing any of the following symptoms?
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Sore Throat
Body Pains
Headache
Fever
Cough
None
Have you worked together or stayed in the same close environment of confirmed Covid case?
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Yes
No
Have you had contact with anyone with fever, cough, colds and sore throat in the past 2 weeks?
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Yes
No
Have you traveled outside the Philippines in the last 14 days?
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Yes
No
Have you traveled outside NCR?
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Yes
No
Submit
