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Museo Sugbo Health Declaration
By completing this form, I consent to Museo Sugbo collecting, using, and storing my personal information for the purpose of compliance with IATF health protocols, policies, and procedures.
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* Indicates required question
Name
*
Your answer
Address
*
Your answer
Mobile Number
*
Your answer
Date of Visit
*
MM
/
DD
/
YYYY
email address
*
Your answer
1. I am a confirmed case of COVID-19 infection.
*
Yes
No
2. In the last 14 day I have had close contact with a person infected with Covid-19.
*
Yes
No
3. In the last 14 days have traveled outside the country.
*
Yes
No
4. In the last 14 days I have had a close contact with a person infected with flu-like symptoms (i.e., fever, cough, sore throat, runny nose, fatigue, difficulty breathing).
*
Yes
No
In the last 48 hours, have experienced flu-like symptoms as follows:
*
fever
cough
sore throat
runny nose
headache, aches, and pains
fatigue
breathing difficulty
none
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