HEALTH DECLARATION FORM
The Roof Bed & Breakfast

Dear Sir/Madam:

To prevent the spread of COVID-19 in our community and reduced the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this agency. Thank you for your time.

1. In the past 14 days, which of the following symptom(s) have you experienced, please check the relevant box(es).

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

3. Have you been identified to high risk areas of COVID-19 in the past 14 days?

If yes, please indicate the area(s)

Declaration and Data Privacy Concent Form

The information I have given id true , correct and complete. I understand that failure to answer any question or giving false answer can be penalized in accordance with law.

I voluntarily and freely consent to the collection nad sharing of the above personal information only in relation to the DepEd Tagum City COVID-19 internal protocols.

   

Signature

Date

Please be advised that the above information shall only be used in relation to DepEd COVID-19 internal protocols in accrodance with Data Privacy Act.

HEALTH DECLARATION FORM

Dear Sir/Madam:

To prevent the spread of COVID-19 in our community and reduced the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this agency. Thank you for your time.
Name :
Type :
Age :
Sex :
Home Address :
Contact Number :
Office :
Office Address :
Person / Office to visit :
Purpose of visit :
Temperature reading :
Date :
Time :
Recorded by Staff (Name) :

1. In the past 14 days, which of the following symptom(s) have you experienced, please check the relevant box(es).

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

3. Have you been identified to high risk areas of COVID-19 in the past 14 days?

If yes, please indicate the area(s)
Declaration and Data Privacy Concent Form
The information I have given id true , correct and complete. I understand that failure to answer any question or giving false answer can be penalized in accordance with law. I voluntarily and freely consent to the collection nad sharing of the above personal information only in relation to the DepEd Tagum City COVID-19 internal protocols.

Signature

   

Date

Please be advised that the above information shall only be used in relation to DepEd COVID-19 internal protocols in accrodance with Data Privacy Act.

SIGNATURE AREA
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