FSUU Health Declaration (1st Sem SY 2022-2023)

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Purpose:

Father Saturnino Urios University (FSUU) prioritizes the health and safety of its employees, students, and other clients as it opens its doors to restricted official transactions and limited face-to-face classes amidst the COVID pandemic.

In response, this Health Declaration Form is meant for FSUU staff, students and guests to assess his/her health risk to the Covid19 infection and for further health evaluation and contact tracing by the FSUU Clinic Triage. This may be shared to health authorities if needed.

Data Privacy Statement:

FSUU assures the respondents of this Health Declaration Form that this is compliant to the Data Privacy Act of 2012 or RA 10173. Therefore, all the data collected will only be used for the purpose stated above. This will be kept in confidentiality and will be destroyed 30 days from the date of accomplishment, following the National Archives of the Philippines protocol.

In pursuance to Republic Act 11332 (Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act), you are required to provide truthful information about your health condition and possible exposure.

Email *

Last Name, First Name, Middle Name: *

Current Address (House #, Street, Brgy, Municipality/City, Province) *

Mobile/Phone Number: *

Are you an FSUU: *

Employee/Staff

Student Assistant

Student

Guest/Visitor

Date: *

YYYY

Time: *

Time

1. Did you experience any of the following for the past week? *

Cough

Fever

Chills

Colds/Nasal Congestion

Body Weakness/Fatigue

Diarrhea

Nausea and Vomiting

Headache

Loss of Smell

Loss of Taste

Sore Throat

Joint/Body Pains

None

Required

2. Have you been exposed to or in close contact with a Covid suspect or Covid positive individual for the past 14 days? *

Yes

Affirmation: *

I hereby affirm, confirm and certify that all the information and answers I have given are complete, true and correct to the best of my personal knowledge and belief. I understand that giving false information may pose a risk to my own health and the health of others. I am fully aware and I understand that any false disclosure, misinformation and falsification or omission of any facts regarding health conditions, prior treatments, medications and recent travel history and possible exposure to a disease of public concern (example, COVID) is punishable by law.

Required

A copy of your responses will be emailed to the address you provided.

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