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1. DMMA COLLEGE OF SOUTHERN PHILIPPINES
(Formerly Davao Merchant Marine Academy)
Tigatto Road, Buhangin, Davao City, 8000
Philippines
HEALTH DECLARATION FORM
(DCSP-MTAC-190, Rev. 1, June 10, 2020)
With the declaration of COVID-19 as pandemic, the health safety of everyone is important to us. Therefore, please fill-out the
following information ACCURATELY AND HONESTLY.
Name:____________________________________________________ Sex:____________________ Age:____________________
Complete Address:_________________________________________________________________________________________
Birth Date:_____________________________________ Contact Number:_____________________________________________
In the past two (2) weeks, have you experienced any of the following? Yes No
1. Respiratory symptoms:
A. Cough
B. Shortness of breath
C. Colds
D. Throat pain
E. Other respiratory symptoms
F. Influenza-like symptoms (headache,, muscle and joint pains, diarrhea, lack of smell or taste
2. Fever of more than 38°C
3. History of COVID-19 infection
4. Household member diagnosed with COVID-19
5. Travel or residence in an area reporting local transmission of COVID-19
6. Contact or exposure to someone with recent travel to an area with local transmission of COVID-19
If you answer YES to any of the questions, refer to the Emergency Department or designated COVID-19 screening facilities.
I hereby attest to the truthfulness of my medical and travel history declaration as stated above. Also, I hereby allow / authorize
DMMA-CSP MTAC to use, collect and process the following information’s for legitimate purposes especially for the prevention and
control of COVID-19 infection.
_______________________________________
Printed Name and Signature
DMMA COLLEGE OF SOUTHERN PHILIPPINES
(Formerly Davao Merchant Marine Academy)
Tigatto Road, Buhangin, Davao City, 8000
Philippines
HEALTH DECLARATION FORM
(DCSP-MTAC-190, Rev. 1, June 10, 2020)
With the declaration of COVID-19 as pandemic, the health safety of everyone is important to us. Therefore, please fill-out the
following information ACCURATELY AND HONESTLY.
Name:____________________________________________________ Sex:____________________ Age:____________________
Complete Address:_________________________________________________________________________________________
Birth Date:_____________________________________ Contact Number:_____________________________________________
In the past two (2) weeks, have you experienced any of the following? Yes No
7. Respiratory symptoms:
G. Cough
H. Shortness of breath
I. Colds
J. Throat pain
K. Other respiratory symptoms
L. Influenza-like symptoms (headache,, muscle and joint pains, diarrhea, lack of smell or taste
8. Fever of more than 38°C
9. History of COVID-19 infection
10. Household member diagnosed with COVID-19
11. Travel or residence in an area reporting local transmission of COVID-19
12. Contact or exposure to someone with recent travel to an area with local transmission of COVID-19
If you answer YES to any of the questions, refer to the Emergency Department or designated COVID-19 screening facilities.
I hereby attest to the truthfulness of my medical and travel history declaration as stated above. Also, I hereby allow / authorize
DMMA-CSP MTAC to use, collect and process the following information’s for legitimate purposes especially for the prevention and
control of COVID-19 infection.
_______________________________________
Printed Name and Signature