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    Student'S Health Assessment Form: YES NO

    Uploaded by

    Michelle Gliselle Guinto Mallare
    This document is a student health assessment form used by Our Lady of Fatima University to screen students for COVID-19 symptoms and risks before allowing them on campus. It asks students to check off if they have experienced any COVID-19 symptoms in the past 14 days or if they have any medical conditions that increase COVID-19 risk. It also asks if students have been exposed to any confirmed COVID-19 cases. By signing, the student agrees that any misinformation could make them liable and that their personal data will be protected according to privacy laws and used to control the spread of COVID-19.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Student'S Health Assessment Form: YES NO

    Uploaded by

    Michelle Gliselle Guinto Mallare
    14 views1 page
    This document is a student health assessment form used by Our Lady of Fatima University to screen students for COVID-19 symptoms and risks before allowing them on campus. It asks students to check off if they have experienced any COVID-19 symptoms in the past 14 days or if they have any medical conditions that increase COVID-19 risk. It also asks if students have been exposed to any confirmed COVID-19 cases. By signing, the student agrees that any misinformation could make them liable and that their personal data will be protected according to privacy laws and used to control the spread of COVID-19.

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    Original Title

    HAF-FOR-STUDENTSv4JNT

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    This document is a student health assessment form used by Our Lady of Fatima University to screen students for COVID-19 symptoms and risks before allowing them on campus. It asks students to check off if they have experienced any COVID-19 symptoms in the past 14 days or if they have any medical conditions that increase COVID-19 risk. It also asks if students have been exposed to any confirmed COVID-19 cases. By signing, the student agrees that any misinformation could make them liable and that their personal data will be protected according to privacy laws and used to control the spread of COVID-19.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    14 views1 page

    Student'S Health Assessment Form: YES NO

    Uploaded by

    Michelle Gliselle Guinto Mallare
    This document is a student health assessment form used by Our Lady of Fatima University to screen students for COVID-19 symptoms and risks before allowing them on campus. It asks students to check off if they have experienced any COVID-19 symptoms in the past 14 days or if they have any medical conditions that increase COVID-19 risk. It also asks if students have been exposed to any confirmed COVID-19 cases. By signing, the student agrees that any misinformation could make them liable and that their personal data will be protected according to privacy laws and used to control the spread of COVID-19.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    STUDENT’S HEALTH ASSESSMENT FORM

    NAME CAMPUS ____________ T

    AGE GENDER CONTACT NOS. YEAR/SECTION COLLEGE/STRAND.

    Mark with a check (✓) your answer to the following questions: YES NO
    1.Have you experienced any of the following in the past 14 days
     Sore Throat
     Body Pain
     Headache
     Fever
     Cough
     Colds
     Difficulty of breathing
     Diarrhea
     Nausea/Vomiting
     Tiredness
     Loss of Taste and Smell
     Skin Rash
     Red Eyes
     Loss of Movement and Speech
     Chest Pain or Pressure
    2. Have you worked together or stayed in the same close environment with a confirmed COVID-19
    case
    or PUI under self-quarantine in your house or in your neighborhood?
    3. Did you have any contact with anyone with fever, cough, colds, and sore throat in the past 14
    days?
    4. Have you travelled outside of the Philippines in the last 14 days?

    5. Do you have any of the following conditions:

     60 years old and above


     Ongoing pregnancy
     Hypertension
     Heart disease
     Diabetes mellitus
     Recurrent asthma attacks
     Chronic lung disease- ongoing PTB treatment
     COPD
     Cancer
     Blood dyscrasias
     Chronic liver and kidney diseases
     Currently undergoing dialysis treatment
     Immunocompromised status
     Autoimmune disease
     Other Illnesses

    I fully understand that it is the policy of the Our Lady of Fatima University that no students regardless of status shall be
    allowed to report for school on campus if any of the abovementioned conditions are present. A student may o nly report back to
    school after fo llowing the 14-day quarant ine protocol and submit a medical clearance/fit to school certificate fro m the School
    Physician before reporting on campus.

    For senior cit izens: I fully understand that I must follow the prevailing guidelines prescribed by the COVID-19
    Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF).
    I attest that all the information given above are true and correct and that I may be held liable for any misinformation
    stated herein. I also authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose of
    effecting the control of COVID-19 infection and that my personal information are protected by RA.10173 (Data Privacy Act
    of 2012) and that I am required by RA.11469 (Bayanihan to Heal as One Act) to provide truthful information.

    Student’s Signature Over Printed Name:

    Date:

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