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    Health Declaration Form


    Name:

    Nationality:

    Gender:

    Age:

    Contact Number:

    Email:

    Passport/Government ID:

    Cities in the Philippines you have worked lived, transited, or visited in the past 14 days


    Have you been sick for the past 30 days?

    Did you have any of the following in the past 14 days?


    Have you been in close contact with farm animals or exposed to wild animals in the past 14 days?


    Have you recently (14 days) traveled to China, any country or place that list local transmission or outbreak of COVID19?


    Have you ever had any recent contact with a person with a confirmed or suspected case of COVID19?


    Do you have any symptoms like fever greater than 38° celsius or flu-like symptoms (cough, flu, difficulty of breathing or shortness of breath)?


    "The declaration I have given herein is true, correct, and complete. I understand that failure to answer any question or falsified response may have serious consequences (Article 171 and 172 of the Revised Penal Code) *Advised by the DOH and DOT, LGU*