REPUBLIC OF THE PHILIPPINES

National Capital Region

STA. ELENA HIGH SCHOOL

STA. ELENA MARIKINA CITY TEL. NO. 8646-9793 8682-3568

Health Checklist
Temperature: Time taken:

Name: ______________________________________ Sex: ___________ Age: ________

Address: ______________________________________________________
Office/Department: Contact Number:
*for VISITORS, fill in company details below:
Person to visit:
Office to visit:
Name: Name of student: Grade & Sec:
If parent/ guardian

PARTICULARS YES NO
a) Fever (Temp. >37.5◦C )
b) Cough/ colds
1. Are you
c) Sore throat
experiencing
d) Body pains
the following
e) Headache
within the past f) Diarrhea/nausea/vomiting
2 weeks: g) Difficulty of Breathing/ Shortness of Breath
h) Loss of sense of smell/taste
2. Have you worked together or stayed in the same close environment of a confirmed COVID - 19
case?

3.Have you travelled outside of the Philippines in the last 14 days?

If yes, please specify. ______________________________________
4. Have you travelled to any area in NCR aside from your home?
If yes, please specify. ___________________________________
5. Have you been recently tested for COVID-19? If yes,
Date of test: _________________ Result: _______________
I hereby authorize Sta. Elena High School to collect and process the data indicated herein for the purpose of effective control of
the COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I
am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

Signature: Date: