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I hereby declare that the information provided are true and correct. REPUBLIC ACT No. 11332 Any person or entity found to have violated Section 9 of this Act shall be penalized with a fine of not less than Twenty thousand pesos (₱20,000.00) but not more than Fifty thousand pesos (₱50,000.00) or imprisonment of not less than one (1) month but not more than six (6) months, or both such fine and imprisonment, at the discretion of the proper court.

1.) Have you travelled to or been in close contact with anyone who has traveled to areas classified as COVID-19 hotspot 14 days from today?

YES NO

2.) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

YES NO

3.) Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problems)?

YES NO

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Firstname:*

Middle Name:

Last Name:*

Date of Birth:*

Year:

Day:

Month:

Cellphone Number:*

E-Mail Address:*

Gender:

Address:*

Country:*

Province:*

City:*

Barangay:*

Zipcode:*

Covid Vaccine Information:

Unvaccinated 1st Dose 2nd Dose Booster

Note to User: Please ensure to take a screenshot of your QR Code otherwise you will have to retrieve it through your registered email address.

By completing this questionnaire, I hereby give permission to provide my personal data to Manuel J. Santos Hospital for procession in relation to COVID 19 screening and contact tracing during this COVID 19 pandemic.