CONTACT TRACING | Villa MJ Maristela

Covid-19 Health Declaration

Contact Tracing Information

First Name

Last Name

Address

Phone

Date

Temperature

Kindly select all that apply to your situation:

I am NOT experiencing the symptoms: fever, cough, sore throat

I have NOT been in close contact with a Covid-19 patient in the last 14 days

I have NOT travelled outside of the country in the past 14 days

Declaration and Data Privacy Consent Form

I declare that the information I have provided is true, accurate, 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 in relation to RCOC COVID-19 internal protocols and for the purpose of affecting control of the COVID-19 infection as required by R.A. 11469, Bayanihan to Heal as One Act.

Thanks for submitting!