Health Declaration Form

Consent*
I agree to the privacy policy.
I declare under violation of Republic Act 11332 that i have NOT been a COVID patient nor have had any close contact with a positive or suspected COVID patient one have displayed any signs and symptoms under#1 ang I have truthfully disclosed the absence of the above signs and symptoms as required under REPUBLIC ACT No. 11332 (An Act Providing Policies and Prescribing Procedures on Surveillance and Response to Notifiable Diseases, Epidemics, and Health Events of Public Health Concern)
Signature*

Do you have the following signs and symptoms of Covid-19 infection, such as:*
- I have Cough or Colds
- I have Difficulty in breathing or shortness of breath
- I have Fever of more than 37.5 C
- I dont have any sympthoms

Covid swab test done:*
- COVID negative swab / No Covid swab done
- COVID positive swab
Date of Swab*
MM slash DD slash YYYY