Office of Commissioner Rey E. Bulay Health Declaration Form

**Ang form na ito ay mayroong Filipino na bersyon, at piliin lamang ito sa mga opsyon taas.

Date*

Date

Name*

Age*

Address of Current Residence*

Email*

example@example.com

1. Are you a previous case or suspect [Person under Monitoring (PUM) / Person under Investigation (PUI) / suspect / probable/ confirmed] COVID-19 patient?*

YesNo

If answer to question 1 is yes, please specify previous case/status

2. Were you exposed to COVID-19 by close contact or travel? **Exposure by contact: 1. Providing direct care to suspect, probable or confirmed COVID-19 patients without proper PPE (i.e., healthcare workers); 2. Face-to-face contact with a probable or confirmed case within 1 meter and for more than 15 minutes; 3. Direct physical contact with a probable or confirmed case; OR 4. Other situations as indicated by local risk assessment. Exposure by travel – travel from a country/area where there is sustained community level transmission to an area with no sustained community transmission*

YesNo

If answer to question 2 is yes, please specify exposure

3. Were you exposed to COVID-19 by residence, i.e., in the locality where you are staying has a sustained community level transmission?*

YesNo

4. Do you live in an area with transmission?*

YesNo

If your answer to question 3 or/and 4 is/are yes, please elaborate your personal exposure and the status or level of transmission in your community

5. Are you part of the vulnerable workforce?**vulnerable workforce:High risk pregnancy, 60 years old and above, any age with co-morbidities, or pre-existing illness (hypertension, diabetes, asthma, COPD, cancer, blood dyscrasias/disease, chronic liver and kidney diseases, or with immunocompromised status)*

YesNo

If answer to question 5 is yes, please specify vulnerability

6. Have you experienced any of the following symptoms in the last fourteen (14) days: sore throat, body pains, headache, fever, including other flu-like symptoms (cough, colds, body malaise, fatigue)?*

YesNo

If answer to question 6 is yes, please specify symptoms

7. Was your latest temperature >37.5˚C?*

YesNo

If answer to question 7 is yes, please indicate latest temperature

I hereby certify that all the answers and information above are true and correct to the best of my knowledge, and any false information I have provided, may constitute grounds for prosecution of perjury. Should symptoms develop after submission of this Health Declaration Form, I hereby commit to inform the Office of Commissioner Rey E. Bulay. (Please sign below)

Ito ang nagpapatunay na ang lahat ng mga sagot at impormasyon sa itaas ay totoo at tama sa abot ng aking kaalaman, at anumang maling impormasyon na aking ibinigay, ay maaaring maging batayan para sa pag-uusig ng perjury. Pag magkaroon ako ng sintomas pagkatapos isumite ang Health Declaration Form na ito, ipaalam ko ito sa opisina ni Commissioner Rey E. Bulay. (Paki-lagdaan sa blangko)

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