healthdec - Culion Foundation, Inc.

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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Date Accomplished *

Name *

First

Last

Age *

Email *

Phone Number *

Foreign Countries or Regions that you have visited in the last 14 days. *

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