CMTF-IMTF-01 CMTF-IMTF-01

V3-09-16-2021 V3-09-16-2021

CITY OF MATI CITY OF MATI

HEALTH DECLARATION HEALTH DECLARATION
(Individual Travel) (Individual Travel)

Date of Entry to Date of Entry to

Mati: Mati:
Contact Number: Contact Number:
Purpose of Stay:  Business  Work  Leisure  Visit Family Purpose of Stay:  Business  Work  Leisure  Visit Family
Length of Stay: Length of Stay:

Place of Origin: Place of Origin:

Barangay | City / Municipality | Province Barangay | City / Municipality | Province
Are you exhibiting any of the following Are you exhibiting any of the following
in the last 10 days: in the last 10 days:
Vaccinated / Vaccinated /
Name: Cough/ Fever Travelled to Name: Cough/ Fever Travelled to
No. of Dose No. of Dose
Colds (Kalintura) High-Risk Colds (Kalintura) High-Risk
(Ubo/Sipon) Area (Ubo/Sipon) Area

Yes No Yes No Yes No Yes No /____ Yes No Yes No Yes No Yes No /____

Vehicle type & Plate number: Vehicle type & Plate number:
Where to stay in Mati? : Where to stay in Mati? :
If staying in boarding house or Name If staying in boarding house or Name
Family members, pls indicate name of Address/ Contact Number Family members, pls indicate name of Address/ Contact Number
owner, address and contact number owner, address and contact number
Data Privacy Notice: The City of Mati – LGU in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed to protect Data Privacy Notice: The City of Mati – LGU in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed to protect
and secure personal information obtained in the performance of its duties. The establishment collects the following personal and secure personal information obtained in the performance of its duties. The establishment collects the following personal
information relevant in the advancement of protocols and precautionary measures against COVID-19 Acute Respiratory Disease. The information relevant in the advancement of protocols and precautionary measures against COVID-19 Acute Respiratory Disease. The
collected personal information will be kept/stored and accessed only by authorized personnel and will not be shared with any outside collected personal information will be kept/stored and accessed only by authorized personnel and will not be shared with any outside
parties unless the disclosure is required by, or in compliance with applicable laws and regulations parties unless the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form: Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of
the above answers. I understand that failure to answer any question or giving false answer can be penalized in accordance with the the above answers. I understand that failure to answer any question or giving false answer can be penalized in accordance with the
law. Relative thereto, I voluntarily and freely consent to the processing and collection of personal data only in relation to COVID-19 law. Relative thereto, I voluntarily and freely consent to the processing and collection of personal data only in relation to COVID-19
internal protocols. internal protocols.

________________________________ ______________________________ ________________________________ ______________________________

NAME AND SIGNATURE DATE NAME AND SIGNATURE DATE
CMTF-IMTF-02 CMTF-IMTF-02
V3-09-16-2021 V3-09-16-2021

CITY OF MATI CITY OF MATI

HEALTH DECLARATION HEALTH DECLARATION
(Group Travel) (Group Travel)

Date of Entry to Date of Entry to

Mati: Mati:
Contact Person: Number: Contact Person: Number:
Purpose of Stay:  Business  Work  Leisure  Visit Family Purpose of Stay:  Business  Work  Leisure  Visit Family
Length of Stay: Length of Stay:

Place of Origin: Place of Origin:

Barangay | City / Municipality | Province Barangay | City / Municipality | Province
Are you exhibiting any of the Are you exhibiting any of the
Name Signature Name Signature
following in the last 10 days: Vaccinated / following in the last 10 days: Vaccinated /
Cough/Colds Fever Travelled to No. of Dose Cough/Colds Fever Travelled to No. of Dose
(Limited to 5 persons per (Limited to 5 persons per
(Ubo/Sipon) (Kalintura) High-Risk (Ubo/Sipon) (Kalintura) High-Risk
declaration) Area declaration) Area
Yes No Yes No Yes No Yes No /____ Yes No Yes No Yes No Yes No /____
Yes No Yes No Yes No Yes No /____ Yes No Yes No Yes No Yes No /____
Yes No Yes No Yes No Yes No /____ Yes No Yes No Yes No Yes No /____
Yes No Yes No Yes No Yes No /____ Yes No Yes No Yes No Yes No /____
Yes No Yes No Yes No Yes No /____ Yes No Yes No Yes No Yes No /____
Vehicle type & Plate number: Vehicle type & Plate number:
Where to stay in Mati? : Where to stay in Mati? :
If staying in boarding house or Name If staying in boarding house or Name
Family members, pls indicate name of Address/ Contact Number Family members, pls indicate name of Address/ Contact Number
owner, address and contact number owner, address and contact number
Data Privacy Notice: The City of Mati – LGU in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed to protect Data Privacy Notice: The City of Mati – LGU in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed to protect
and secure personal information obtained in the performance of its duties. The establishment collects the following personal and secure personal information obtained in the performance of its duties. The establishment collects the following personal
information relevant in the advancement of protocols and precautionary measures against COVID-19 Acute Respiratory Disease. The information relevant in the advancement of protocols and precautionary measures against COVID-19 Acute Respiratory Disease. The
collected personal information will be kept/stored and accessed only by authorized personnel and will not be shared with any outside collected personal information will be kept/stored and accessed only by authorized personnel and will not be shared with any outside
parties unless the disclosure is required by, or in compliance with applicable laws and regulations parties unless the disclosure is required by, or in compliance with applicable laws and regulations
Declaration and Data Privacy Consent Form: Declaration and Data Privacy Consent Form:
I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of
the above answers. I understand that failure to answer any question or giving false answer can be penalized in accordance with the the above answers. I understand that failure to answer any question or giving false answer can be penalized in accordance with the
law. Relative thereto, I voluntarily and freely consent to the processing and collection of personal data only in relation to COVID-19 law. Relative thereto, I voluntarily and freely consent to the processing and collection of personal data only in relation to COVID-19
internal protocols. internal protocols.
______________________________ ______________________________
DATE DATE