NIMBB Health Declaration Form

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The information you provide here may be used by public health authorities, in accordance with Philippine legislation, in the context of the public health response to COVID-19. This form must be completed for every entry into the NIMBB building.

Name *

Please enter your full name (Last name, first name)

E-mail Address *

Please use your UP mail if you have one.

Designation *

Faculty

Staff

Student

其他:

Mobile Number *

Enter your mobile number using this format: 09XXXXXXXXX

Date of Entry to NIMBB *

Enter the date and time of entry to the NIMBB building.

年

月

日

时间

Body Temperature *

Provide your body temperature reading upon entry.

Are you experiencing any of the following symptoms in the past 7 days? *

Check all that apply.

Fever

Cough and/or Colds

Body Pains

Sore Throat

Fatigue/Tiredness

Headache

Diarrhea

Loss of Taste or Smell

Shortness of Breath

None

必填

Have you had face-to-face contact with a suspected or confirmed COVID-19 case within 1 meter and for more than 15 minutes in the past 7 days? *

Yes

Have you traveled outside the Philippines in the last 14 days? *

Yes

Have you traveled outside the current city/municipality where you reside in the past 7 days? *

Yes

If yes, specify which city/municipality you went to:

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