Date Signed


Republic of the Philippines

Municipality of Palo

Province of Leyte

Municipal Health Office



INSTRUCTION: Kindly fill-out ALL the needed information.

Last Name*: ____________________________________

First Name*: ____________________________________

Middle Name*: __________________________________

Suffix*: _________________

Birthdate*: ______________

Contact No.*: ___________________________________

Full address*: ___________________________________


Barangay*: ________________________

Sex*: ____________________

Civil Status*: ______________

Occupation*: ______________


01_A1. Health Care Worker

Priority Group: ____________

Occupation: _________________________________

Name of Institution/Facility: _____________________

02_A2. Senior Citizen

03_A3. Adult with comorbidity

04_A4. Frontline Personnel in Essential

05_A5. Poor Population

06_B1. Teachers and Social Workers

07_B2. Other Government Workers

08_B3. Other Essential Workforce

09_B4. Other Socio-demographic Groups

10_B5. Overseas Filipino Workers

11_B6. Other remaining workforce

12_C. Rest of the Population

Phil Health ID Number*: ____________________________

Passport Number: _________________________________

PWD ID / Senior Citizen ID Number*: __________________

Employment Status*:





05_Others : _______________________________________

Health Declaration:

Do you have any history of the following allergies? (Drug, Food, Insect, Latex, Mold, Pet, Pollen Allergy)



Do you have any of the following conditions?

(Hypertension, Heart Disease, Kidney Disease, Diabetes Mellitus,

Bronchial Asthma, Immunodeficiency Status, Cancer and other conditions that may require medical certificate)

01_Yes 02_No

Do you have any previous severe allergic reactions during / after vaccination/immunization?



Have you received any vaccine for COVID-19 in the past?




What vaccine: _______________________

When: _____________________________

Where (Facility): _____________________

If NO, are you willing to be vaccinated for COVID-19?

01_Yes 02_No

Reference Number: ________________________

I hereby consent to the collection of sensitive personal information by the government as the same is necessary to respond to a national emergency brought by the COVID-19 pandemic. I understand that by giving these sensitive personal information regarding my health and medical history/condition, the same shall be used by the government for the purpose of determining the propriety of administering upon myself a vaccine against COVID-19. By giving such consent, I hereby waive my right to confidentiality on the sensitive personal information I disclosed to the government, thereby waiving any action or claim against the government for any damage or harm that may arise from such disclosure of personal information.

I, after having been examined regarding my medical history/ condition and was found to be suffering from a disease, I hereby submit my medical clearance from my physician or waive the presentation of the same.

This is to certify that the information provided above is true and correct to the best of my knowledge and I am a resident of this Barangay.

(Ako in nagpapamatuod nga ako naka-intindi ngan na-eksplikaran hin klaro ug maupay pinaagi han Waray-Waray nga yinaknan han mga impormasyon nga nakabutang hini nga dokumento. Ako in mapirma hini nga dokumento nga waray pag-alang o pagruhaduha, ngan waray pagpirit o

pagimpluwensiya tikang hin iba nga tawo.)





Signature over Printed Name

Date Signed




This is to certify that the person mentioned above is a resident of this Barangay.


Signature over Printed Name Punong Barangay/Authorized Representative