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    Health Declaration Form - SCHOOL LEARNERS

    Uploaded by

    Leuqabracyaanab Sorevotlaonrutnoc Soluenabenelia
    This document is a health declaration form used by Sta. Cruz Integrated School to screen for COVID-19 symptoms among students. The two-page form collects students' personal information, conducts a basic health screening by having students check any symptoms experienced in the past 14 days, and asks if they have been in contact with COVID-19 patients or at high risk areas. Students and parents must sign to consent to the collection and sharing of personal health information only as it relates to the school's COVID-19 protocols and in accordance with data privacy laws.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Health Declaration Form - SCHOOL LEARNERS

    Uploaded by

    Leuqabracyaanab Sorevotlaonrutnoc Soluenabenelia
    106 views1 page
    This document is a health declaration form used by Sta. Cruz Integrated School to screen for COVID-19 symptoms among students. The two-page form collects students' personal information, conducts a basic health screening by having students check any symptoms experienced in the past 14 days, and asks if they have been in contact with COVID-19 patients or at high risk areas. Students and parents must sign to consent to the collection and sharing of personal health information only as it relates to the school's COVID-19 protocols and in accordance with data privacy laws.

    Original Title

    Health Declaration Form_SCHOOL LEARNERS

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    This document is a health declaration form used by Sta. Cruz Integrated School to screen for COVID-19 symptoms among students. The two-page form collects students' personal information, conducts a basic health screening by having students check any symptoms experienced in the past 14 days, and asks if they have been in contact with COVID-19 patients or at high risk areas. Students and parents must sign to consent to the collection and sharing of personal health information only as it relates to the school's COVID-19 protocols and in accordance with data privacy laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    106 views1 page

    Health Declaration Form - SCHOOL LEARNERS

    Uploaded by

    Leuqabracyaanab Sorevotlaonrutnoc Soluenabenelia
    This document is a health declaration form used by Sta. Cruz Integrated School to screen for COVID-19 symptoms among students. The two-page form collects students' personal information, conducts a basic health screening by having students check any symptoms experienced in the past 14 days, and asks if they have been in contact with COVID-19 patients or at high risk areas. Students and parents must sign to consent to the collection and sharing of personal health information only as it relates to the school's COVID-19 protocols and in accordance with data privacy laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Republic of the Philippines EN

    T OF ED
    Department of Education M

    U
    T

    CA
    DEPAR
    Region X

    TION
    Division of Misamis Occidental
    DISTRICT OF PLARIDEL NORTH

    AL
    MI
    AM T

    S
    STA. CRUZ INTEGRATED SCHOOL I S OCCIDEN

    Sta. Cruz, Plaridel, Misamis Occidental, 7209

    Office of the School Principal Cellphone No.: 0939-280-8790


    SCHOOL ID: 501870 Email address: 501870@deped.gov.ph

    HEALTH DECLARATION FORM FOR SCHOOL LEARNERS

    Dear Sir/Madam:
    To prevent the spread of COVID-19 in our community and reduce 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 school. Thank you
    for your time.

    Name:
    Age: Sex: Grade Level:
    Home Address:
    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)
    Fever Dry cough
    Sore throat Tiredness
    Diarrhea Shortness of Breath
    Body Aches Runny Nose
    Headache Others
    NONE OF THE ABOVE
    2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days?
    Yes No
    3. Have you been identified to high risk areas of COVID-19 in the past 14 days?
    Yes No

    Declaration and Data Privacy Consent Form:

    The information I have given is 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 and sharing of the above-personal information
    only in relation to the DepEd Misamis Occidental 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 accordance with the Data Privacy Act.

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