Republic ofthe Philippines Department of Education Cordillera Administrative Region DIVISION OF BAGUIO CITY #82 Miltary Cut-Off, Baguio Cty REQUEST FOR QUOTATION ‘Standard Form No:SF-GOOD-60 Revised on: May 24, 2008 Standard Form Te: Request for Quotation Supplier: Requesting Unit: ‘Address: PR No,: 2018-05-113 Telephone No.: Quotation No.: 2018-05-108 e-Mail: Date: May 24, 2018 Date received by the Supplier: ‘ABC: 80,000.00 Please quote your lowest price on the item/s listed, subject to the General Conditions below, stating the shortest time of delivery and submit your quotation in a sealed envelope duly signed by your representative not later than _3-3!~%e\6 @ 1 SORA Palak CO1C Assistant School Division Superiniladkat , Chairman, Bids and Awards Committee yy REQUIREMENTS: 1. Mayor's / Business permit 2. PhiIGEPS registration number or certificate 3. Omnibus Sworn Statement Note: Submit RFQ together with the requirements, Al entries must be typewritten or legibly written. Indicate brand and model of item offered Delivery period within Calendar Days. Price validity shall be for a period of 30 Calendar Days. e044 Item | Qty. | Unit | Item Description z [eres Total Price | No. S°x11” /22x28 cm { Piece | Hard paper | School Health Examination Card (Back to Back) | a **Please see attached sample | a TOTAL = Purpose: School health examination cards for the use of dental personnel for individual health cards on oral exam to pupils After having carefully read and accepted your General Conditions, /We quote you on the item at prices noted above. Signature over Printed Name Tin Datel Telephone No. Canvassed by: poste m PHILGEPSRepubli of the Pitippines ‘ Department of Education Pasig City SCHOOL HEALTH EXAMINATION CARD lementary Pup NAME. SCHOOL Tost Tint Mite Date of Birth Region Vom Day Tar Birthplace Division Telephone No, Grades | Grades | Grades | Graded & Intervention Intervention Intervention Intervention Intervention Date of Examination “Temperature/BP Heart/Respiratory Pulse Rate Height Weight Nutritional Status (NS) Vigual Acuity (Snelien's) ANRGD.N LEG ADN Rt d. ADN Lf Hearing Tuning Forky AN'REMN Te ADN Red. ADN LE ‘SKin/Seal Eyes/EarsiNowe Mouth/Throav Nek Lungs/Heart ‘Abdomen/Genitala ‘Spine’Extremities ‘Others, specify Examined by Seal rerEariNose | Mouth/Neck/Throat | Lungsiea ‘Abdomen’ Spine? NS. ‘SkinSealp Eye 1outh/Neck/ Th Lungutfeart — ee 7 Normat = Normatese | a Nonwal mouth | a Normalluegs | a Normal 7 Normal Abdomen spine. 1 Fedicalook |b Normal ears | Normal treat —[ b, Normal heart TN Upper | by Needs clone Normal Extremities | supervision Above |e Tinea lana | Normalan |e Enlarged tons | c Rakes = Nees ‘Normal vith exudates Follow-up TRingrorm | a squinting Tip esion ener aE Mlemorrhoids | @ Scoliosis | & Corrected eFevema Pale © Enlarged tonsil | «. Murmur | e-Teaderacss |e Lordosis | © Treated conjunetivae | “w/o exudates Timpetgor Tear TTaflamed pharynx | (Deformed | 1. Gealtal TE Ryphoss | CAdvised bail discharge chest Discharge Counseed Elematoma | & Impacted = Enlarged iyraid |g Distant heart | @ Hernia we owieas | g Referred seramen land sounds Knock knees Brakes T-Sepat Te Speeth defect | hs vegular ‘Oiber T.Flatfoot | hs Parca detiation heart rate specify noted T caw Tas [Dental probiem 1 Others, iab foot] Others, lacerations discharze specify spel Tallersy 7 Others. 7 Others, J Others, speci speity spells TOhers, speily Note: Use letter to record ailments aad place N if aot examinedRepublic of te Philippines Depuaetment of Education Pasig City SCHOOL ORAL HEALTH EXAMINATION CARD ementary Papils MEDICAL HISTORY Guided Questions ne Do youhave atoothorush?_ ab ceding Prob thw wany tne do you truss your eth? ___onen__2_8t teen al How many times do you change your toothbrush ina year? Tepsy aaa Do you use toothpete in brushing? N ing Hom many ee doyou vet the denen ayom?__onee_2x ‘CONDITION AND TREATMENT NEEDS eRe CoN ION Peescnne] «]2] 3] «] 2] = 2s 3 rch s[sfe[s[alels[@[e] ut Tanga TOMORARYIEELL Periodontal Disease | |Malocclusion r Supernamerary woth ge Le fos es fo fa fae ae] ears : Decubital ulcer 3 eatcuns Eas [a7 [ac [as | | [2 | a1 | a0 [2 [33 [34 [a5 | 56 [37 [38] [Cromuprpaate nc Root regret cl | TEMPORARY TEETH eee wont [as[sifas|m|o|n[a|7|u fs] vert conoimion DENTAL PROCEDURES: er ae, paisa asx al Neca tt. Persaud sa] a] Tee No. Tidecayed No.ited Toad dt PERMANENT TEETH POSTE Ora aT eee Passed Tels [e[eTs No. ibecayed No. TiMssing No. Filed ToalDMFT. Total Sound Teeth, Reet rnrcmtene| ee ee eae