Republic of the Philippines

Department of Health
EASTERN VISAYAS
Center for Health Development

Checklist for Persons under Monitoring (PUM)

(For the use of BHERT only)

Name: Age: Sex: Nationality: Primary Contact Number:

Address: No. of persons Other health Hypertension Asthma

in the condition Secondary Contact Number:
household: Please check -
Diabetes Others (please
specify):

History of travel to other countries / areas Date returned to Date Returned Flight No.
(please specify including duration of stay): Philippines: to specific
province: Seat No.

Name of vessel:

Accommodation:

History of exposure Yes Nature of contact: Date of last Casual contact:

to a confirmed exposure to Close contact:
covid19 patient Casual conformed  With confirmed case of covid-19 within 14 days of
covid-19 illness
 Visited/ worked in live animal marker in China 14
No patients:
days prior to onset of symptoms
 Worked in hospital where covid19 infection was
Close reported
 Health care worker assigned in environment where
SAR infection of unknown etiology were attended

Symptom Diary (please check accordingly)

Symptoms
Day Date No Fever equal to Sore Throat Cough Runny Nose Shortness of Diarrhea
Symptom or more than Breath
s 38 C
Yes No Yes No Yes No Yes No Yes No Yes No
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Any household contact with clinical symptoms within 14 days of exposure contact with the primary case should be considered a symptomatic and so a possible suspect
If you develop any of the symptoms listed during the observation period, please inform any of the contact below

Barangay Chairman Health Worker MLGOO

Contact Number Contact Number Contact Number

Reference Household transmission investigation protocol for 2019 nCoV Version 1.1. January 25, 2020. WHO

Noted by: Ma. Dollyne B. Malinao

Municipal Health Officer