MSAS COVID-19 HEALTH DECLARATION FORM (HDF)

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Kindly fill-out this form prior to the sport event or activity.

We will use this as a screening tool prior to your admission to the sport event.

Thank you for your cooperation and understanding.

PSC-MSAS

Email *

Did you avail your Covid 19 Vaccine? *

Yes

If Yes, what vaccine was given to you?

How many dose (s) of vaccine have you received? *

1 (Primary)

2 (Primary)

Booster (1st)

Booster (2nd)

None

Other:

Write the name of the event you are attending *

PERSONAL INFORMATION

Contact details are important in case of possible Contact Tracing.

Name *

Age (last birthday) *

For athlete/coach, write your sport/event (e.g. athletics, swimming, taekwondo)

For PSC employee, write your department

Cellphone number *

ADDRESS where you reside/stay in the last 30 days (include barangay name and/or number) *

HEALTH-RELATED INFORMATION

In the last 14 days, I experienced Flu-like symptoms ("trangkaso"). *

Yes

If you answered YES, check the symptom/s you have experienced.

Fever

Cough

Colds

Difficulty of breathing

Sorethroat

Body weakness

Body pains

Headache

Loss of taste

Loss of smell

Diarrhea

Other:

If you checked OTHER, please specify the sign or symptom

I was diagnosed by a doctor to have chronic* medical condition/s (ex. Hypertension, Diabetes, etc.) *

Yes

If Yes, check medical condition/s that you have

Hypertension

Heart Disease

Diabetes

Chronic Kidney Disease

Chronic Liver Disease

Bronchial Asthma

COPD (Chronic Obstructive Pulmonary Disease)

Cancer (any type)

Obesity

Other:

For Females: I am pregnant

Yes

Not sure

Clear selection

I am presently taking maintenance medication/s *

Yes

If Yes, list down name/s of your maintenance medication/s

I am undergoing dialysis *

Yes

I am undergoing chemotherapy *

Yes

I am undergoing other treatment modality *

Yes

If Yes, list other treatment modality you are undergoing

AUTHORIZATION

I hereby authorize the Philippine Sports Commission to collect and process the data indicated herein for the purpose of effecting control of the COVID-19 disease. I understand that my personal information is 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.

I certify that the above declarations in the Health Declaration Form are accurate and true.

****END****

Send me a copy of my responses.

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