HEALTH DECLARATION FORM Valid on day of consult only. Present this to the department you will visit.

You must provide TRUTHFUL information about YOUR HEALTH condition and possible exposure. Any falsification is PUNISHABLE with one to six months IMPRISONMENT and a 20, 000 to 50,000 FINE (Republic Act 11332) Full Name: ________________________ Date Accomplished: _________ Contact Number: ________________ Address: _______________________________________________________ Instruction: Please tick the appropriate response if YES or NO

EXPOSURE WITHIN THE PAST 14 DAYS (from date of visit) YES NO

1. Did you have any intentional or local travel or are residing in a place with reported increase of COVID-19 cases within the past 14 days. ?

2. Did you have any direct exposure (within 2 meters and for more than 15 minutes without wearing mask/N95 respirator) with a person positive for COVID-19?

3. Do you have a pending COVID-19 test result (RT-PCR or Rapid Anti-body Test)?

4. Have you been tested positive for COVID-19?

SIGN AND SYMPTOMS (During the date of visit) YES NO

5. Do you have any of the following sign and symptoms? Fever of more than 38*C Difficulty of breathing Cough Shortness of breath Colds Influenza-like symptoms (head-ache, muscle and Sore throat joint pains, lack of smell or taste)

6. Have your signs and symptoms not improved

For any further inquiries, kindly call the extension number of the unit you intend to visit. The undersigned declares that the information contained in this Health declaration Form is true and I am legally liable for any falsification contained therein. ______________________ Signature of Accomplisher

SOUTHWOODS MALL

COVID-19 VACCINATION CENTER CITY HEALTH OFFICE 1

Vaccinee Record Form

Vaccinee Control Number :______________________ Name:____________________________ Sex: ______ Age: _______ Birthday:__________________________ Complete Address: ____________________________________Contact Number: _______________________ Contact Person in case of emergency: _______________________Relation to the vaccinee________________ Contact Number: __________________________ I.D Number : __________________________ Type of ID: ____________________

Pre- Vaccination Screening Notes 1st dose

Pre- Vaccination Screening Notes 2nd dose

Temperature : ___________ BP:____________ Heart rate: _____________ RR: ___________

Temperature : ___________ BP:____________ Heart rate: _____________ RR: ___________

Doctors Notes: Doctors Notes:

꙱ Vaccinate ꙱ Do not Vaccinate ꙱ Other instructions:

꙱ Vaccinate ꙱ Do not Vaccinate ꙱ Other instructions:

VACCINE DETAILS

Dosage Sequence Vaccination Site Date Vaccine Brand Batch Number Lot Number

1st Dose Left Right

Vaccinators Name: Signature:

2nd Dose Left Right

Vaccinators Name: Signature:

POST VACCINATION NOTES 1st dose

POST VACCINATION NOTES 2nd dose

꙱ Discharge and no symptoms observed ꙱ Symptoms was observed and managed. Discharge after resolution of symptoms ꙱ Referred to hospital Note: Document the event in the AEFI Case report form for mild and moderate symptoms and use AEFI Case Investigation Form. Monitored by: ____________________________

꙱ Discharge and no symptoms observed ꙱ Symptoms was observed and managed. Discharge after resolution of symptoms ꙱ Referred to hospital Note: Document the event in the AEFI Case report form for mild and moderate symptoms and use AEFI Case Investigation Form. Monitored by: ____________________________

SOUTHWOODS MALL

COVID-19 VACCINATION CENTER CITY HEALTH OFFICE 1

SOUTHWOODS MALL – CITY HEALTH OFFICE 1

SOUTHWOODS MALL – CITY HEALTH OFFICE 1

MGA PAALALA MATAPOS MABAKUNAHAN

Sa Kinauukalan: Naipaliwanag sa aking ng maayos at malinaw ang MGA PAALALA MATAPOS MABAKUNAHAN. Nabigyan ako ng pagkakataon magtanong at ito ay nasagot ng malinaw at maayos. __________________________ __________________________ Pangalan at lagda ng Vaccinee Pangalan at lagda ng nag-discharge Petsa at Oras: ___________

MGA PAALALA MATAPOS MABAKUNAHAN

1. Ang mga sumusunod ay ang inaasahang side effect ng bakuna na mawawala rin matapos ang

ilang araw:

a. Masakit at pamamaga ng pinagturukan b. Lagnat c. Pananakit ng ulo d. Pakiramdam ng pagkapagod e. Chills

2. Ilang araw lamang ang mga side effects na ito. Maaring ilapat sa pinagturukan ang basang malamig na tuwalya o i-exercise ang braso. Kung lalagnatin, uminom ng maraming tubig at magsauot ng preskong damit.

3. Kung ang mga sintomas ay magpapatuloy o may iba ang maramdaman, mag pa check-up sa inyong doctor o sa pinaka malapit na health center sa inyong lugar.

4. Dalawang dose ng bakuna ang kailangan para sa inyong proteksyon. Magpabakuna pa rin kahit makaranas ng side effect maliban na lamang kung ito ay i-defer ng doctor.

5. Bibilang ng ilang araw bago makabuo ang iyong katawan ng proteksyon na mula sa bakuna. Sa kaso ng COVID-19 vaccine maaring bumilang ng 1-2 linggo bago umepekto ang proteksyon ng bakuna pagkatapos ng iyong pangalawang dose.

6. Kahit kumpleto ang bakuna, patuloy pa rin i-practice ang mga sumusunod: a. Physical Distancing b. Pagsusuot ng mask at face shield c. Palaging paghuhugas ng kamay d. Manatili sa bahay kung may sakit o hindi naman mahalaga ang kailangan sa labas.

7. Para sa karagdagan impormasyon: a. Bisitahin ang website ng DOH at ng City Health Office 1 b. Tumawag sa hotline: CHO1: 049 511-8142 or sa

C3 hotline: SMART: 09089879711 GLOBE: 09171208911 INTELCO: 049 (513) 9111 PLDT: 049 52359111

8. Ang inyong sunod na schedule ng bakuna ay sa ________________________ Kung meron mga Sintomas na maramdaman pagkatapos bakunahan, Maari nyo pong

report sa ating City Epidemiology & Surveillance Unit. I scan lamang ang QR code na ito:

SOUTHWOODS MALL

COVID-19 VACCINATION CENTER CITY HEALTH OFFICE 1