PROVINCIAL GOVERNMENT OF TARLAC

HEALTH DECLARATION FORM

PERSONAL DETAILS
LAST NAME: FIRST NAME: MIDDLE NAME: SUFFIX:

CONTACT NUMBER: EMAIL ADDRESS: GENDER: PREGNANT:

[ ] Male [ ] Yes
DATE OF BIRTH (mm/dd/yyyy): COMPANY/SCHOOL NAME: [ ] Female [ ] No

OCCUPATION: ADDRESS: FOREIGNER: [ ] Yes [ ] No

If Yes, indicate Nationality:

RESIDENCE:
House Number/Sitio/Purok/Street Barangay Municipality/City Province

TRAVEL DETAILS
PURPOSE OF TRAVEL TO TARLAC: TRAVELLER TYPE:

PLACE OF ORIGIN: DESTINATION:

ENTRY DATE: EXIT DATE:

MODE OF TRANSPORT: Vehicle Plate Number:

[ ] Motorcycle
[ ] Private Vehicle
[ ] Public Transport Vehicle Model/Type:
[ ] Walk/Bicycle

DOCUMENTS REQUIRED TO BE PRESENTED AT THE BORDER CONTROL CHECKPOINT

[ ] Travel Pass issued by LGU of Origin [ ] Negative RDT Result
[ ] Valid Government/Company ID or Certificate/Proof of Employment Date Tested ___________________
[ ] Negative RT-PCR Result
Date Tested _______________
DECLARATION AND DATA PRIVACY CONSENT FORM
The information I have given are true, correct, and complete. I understand that failure to answer any question or giving false answers can
be penalized in accordance with the law.

I voluntarily and freely consent to the collection and sharing of the above personal information only in relation to the PGT COVID-19
internal protocols.

CONSENT FOR QUARANTINE

If found necessary, I am willing to undergo the required quarantine procedures and shall follow the advice of the Provincial/Rural Health
Physician and Surveillance Nurse.

____________________________________________________________ _________________________________________________
Signature over Printed Name Date

Please be advised that the above information shall only be used in relation to the PGT COVID-19 internal protocols in accordance with
the Data Privacy Act. For any concerns, you may contact covidtarlac@gmail.com.

HOTLINES: Landline: (045) 982 1872 Smart: 0919 065 9289 Globe: 0917 123 0989 EMAIL: covidtarlac@gmail.com
FACEBOOK PAGE: facebook.com/ProvincialGovernmentofTarlac