JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
JALAJALA COVID-19 VACCINATION REGISTRATION
Data submitted through this form shall remain confidential and will only be used by the Municipality of Jalajala Rizal - Rural Health Unit to gather data needed for COVID-19 Vaccination. This pre-registration is open to individuals aged Eighteen (18) Years and Older.
PREPARE ID (IDENTIFICATION NO. AND PHILHEALTH NO. if available.)
*Required
Sign in to Google
to save your progress.
Learn more
* Indicates required question
GROUP (Grupo)
*
GROUP A: Frontline Health Workers, Senior Citizens, Vulnerable at Co-Morbid Groups, Indigent Population, at Uniformed Personnel
GROUP B: Teachers at School Workers, Iba pang kawani ng gobyerno, essential workers, OFWs, natititrang kasapi ng workforce, at mga estudyante
GROUP C: Mga natitirang Filipino Citizen
Required
CATEGORY (Kategorya)
*
Health Workers
Senior Citizen
Indigent
Uniformed Personnel
Essential Worker
Others
Required
CATEGORY ID (Identipikasyon)
*
PRC number
OSCA number
Facility ID number
Other ID
Required
ID NUMBER (Numero ng napiling Identipikasyon)
*
Your answer
PHILHEALTH ID No. (if available) / None (Wala)
Your answer
PWD ID No. (Iwanang blangko kung wala)
Your answer
LAST NAME (Apelyido)
*
Your answer
FIRST NAME (Pangalan)
*
Your answer
MIDDLE NAME (Gitnang Pangalan)
*
Your answer
SUFFIX (NA - Kung Wala / Not Applicable)
NA
II
III
IV
V
JR
SR
Clear selection
CONTACT NUMBER (Numero)
*
Your answer
HOUSE NO. AND STREET (Numero ng Bahay, Pangalan ng Kalye)
*
Your answer
REGION (Rehiyon)
*
CALABARZON
OTHER:
Required
PROVINCE (Probinsya)
*
_0458_RIZAL
Other:
Required
MUNICIPALITY (Munisipalidad)
*
JALAJALA
OTHER:
Required
BARANGAY
*
BAGUMBONG
BAYUGO
FIRST/SPECIAL DISTRICT
LUBO
PAALAMAN
PAGKALINAWAN
PALAYPALAY
PUNTA
SECOND DISTRICT
SIPSIPIN
THIRD DISTRICT
Required
If NOT from Jalajala Rizal, Indicate your BARANGAY below. (Kung Hindi Tiga-Jalajala, ilagay kung saang barangay nakatira)
Your answer
SEX (Kasarian)
*
Male
Female
Required
BIRTHDAY (Kapanganakan)
*
MM
/
DD
/
YYYY
CIVIL STATUS (Estado Sibil)
*
Single
Married
Widow/Widower
Separated/Annuled
Living with Partner
Required
EMPLOYMENT STATUS (Estado ng Trabaho)
*
Government Employed
Private Employed
Self Employed
Private Practitioner
Other:
Required
NAME OF EMPLOYER/ESTABLISHMENT (Kung Saan Nagtatrabaho) or NONE (Wala)
*
Your answer
PROFESSION (Propesyon/Trabaho)
*
Your answer
NAME OF EMPLOYER/ESTABLISHMENT (Kung Saan Nagtatrabaho) or NONE (Wala)
Your answer
LOCATION OF EMPLOYER (Lugar Kung Saan Nagtatrabaho, )
Your answer
If not in the choices above, Indicate Location (Kung wala sa pagpipiliian ang sagot, ilagay sa ibaba)
Your answer
CONTACT NUMBER OF EMPLOYER
Your answer
WITH DIRECT INTERACTION TO COVID PATIENTS (May direktang interaksyon sa mga pasyenteng may COVID-19)
*
Yes
No
Required
PREGNANT (Buntis?)
*
PREGNANT
NOT PREGNANT
DRUG ALLERGY (Allergy sa Gamot)
*
YES
NO
FOOD ALLERGY (Allergy sa Pagkain)
*
YES
NO
INSECT ALLERGY (Allergy sa Kagat ng Insekto)
*
YES
NO
LATEX ALLERGY (Allergy sa Latex/Gloves)
*
YES
NO
MOLD ALLERGY (Allergy sa Mold/Amag)
*
YES
NO
PET ALLERGY (Allergy sa Hayop)
*
YES
NO
POLLEN ALLERGY (Allergy sa Pollen)
*
YES
NO
COMORBIDITY? (May Iba Pang Sakit?)
*
YES
NO
HYPERTENSION (High Blood?)
*
YES
NO
HEART DISEASE (Sakit Sa Puso?)
*
YES
NO
KIDNEY DISEASE (Sakit Sa Bato?)
*
YES
NO
DIABETES
*
YES
NO
ASTHMA
*
YES
NO
HIV/AIDS (Confidential, Ang sagot ay manantiling kompidensyal)
*
YES
NO
CANCER
*
YES
NO
OTHER DISEASES (May iba pang sakit maliban sa nabanggit?)
*
YES
NO
HAVE YOU EVER HAD COVID-19? (Nagkaroon Ka Na Ba Ng COVID-19)
*
YES
NO
Date Diagnosed with COVID-19? (Petsa Kung Kailan Nagkaroon Ng COVID?)
MM
/
DD
/
YYYY
CLASSIFICATION OF COVID-19 (Klasipikasyon Ng COVID) (Leave blank if NOT APPLICABLE)
Asymptomatic
Mild
Moderate
Severe
Critical
Are you willing to get vaccinated? (Handa Ka Ba Na Magpabakuna)
*
Yes (Oo, Handa na!)
No (Hindi)
PREFERRED COVID VACCINE (Ano ang bakuna na gugustuhin mong matanggap?)
*
Sinovac
AstraZeneca
Moderna
Pfizer/BioNTech
Gamaleya (Sputnik V)
Novavax
Johnson & Johnson/Janssen
Whatever is Available (Kahit Anong Bakuna Ang Nasa Vaccination Center)
Other:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
