BARANGAY BEL-AIR

HEALTH DECLARATION FORM

1. Are you experiencing or did you have any of the following in the last 14 days? (Ikaw ba ay may nararanasan o nakakaranas ng mga sumusunod na sintomas sa nakaraang 14 na araw?)

A. FEVER (LAGNAT)
B. COUGH AND/ OR COLDS (UBO AT/O SIPON)
C. BODY PAINS (PANANAKIT NG KATAWAN)
D. SORE THROAT (PANANAKIT O PAMAMAGA NG LALAMUNAN
E. FATIGUE/TIREDNESS PAGKAPAGOD
F. HEADACHE (PANANAKIT NG ULO)
G. DIARRHEA (PAGTATAE)
H. LOSS OF TASTE OR SMELL (NAWALAN NG PANLASA O PANG-AMOY)
I. DIFFICULTY OF BREATHING (PAGKAHAPO O HIRAP SA PAGHINGA)
2. HAVE YOU HAD FACE-TO-FACE CONTACT WITH PA PROBABLE OR CONFIRMED COVID-19 CASE WITHIN 1 METER AND MORE THAN 15 MINUTES FOR THE PAST 14 DAYS? (MAY NAKASALAMUHA KA BA NA MAAARING O KUMPIRMADONG PASYENTE NA MAY COVID-19 MULA ISANG METRONG DISTANSYA OR MAS MALAPIT PA AT TUMAGAL NG MAHIGIT 15 MINUTO SA NAKALIPAS NA 14 ARAW?)
3. HAVE YOU PROVIDED DIRECT CARE FOR A PATIENT WITH PROBABLE OR CONFIRMED COVID-19 CASE WITHOUT USING PROPER " PERSONAL PROTECTIVE EQUIPMENT (PPE)" FOR THE PAST 14 DAYS? (NAG-ALAGA KA BA NG MAAARING O KUMPIRMADONG PASYENTE NA MAY COVID-19 NG HINDI NAKASUOT NG TAMANG PPE (PERSONAL PROTECTIVE EQUIPMENT) SA NAKALIPAS NA 14 ARAW?)
4. HAVE YOU TRAVELED OUTSIDE THE PHILIPINES IN THE LAST 14 DAYS?(IKAW BA AY NAGBIYAHE SA LABAS NG PILIPINAS SA NAKALIPAS NA 14 NA ARAW?)
5. HAVE YOU TRAVELED OUTSIDE THE CURRENT CITY/MUNICIPALITY WHERE YOU RESIDE?(IKAW BA AY NAGBIYAHE SA LABAS NG IYONG LUNGSOD/MUNISIPYO?) I

        I hereby authorize Brgy. Bel-air to gather, collect and use the data indicated herein for contact tracing purposes in effecting control of the COVID-19 transmission. I fully understand that the personal information provided is protected by RA10173 better known as the Data Privacy Act of 2012 and that this registration form will be destroyed 30 days from accomplishment date following protocols from the National Archives of the Philippines.

Thanks for submitting!