Republic of the Philippines

Department of Education
Region III
Schools Division Office of Pampanga
TEACHER'S PROFILE

District: School:

No. COMPLETE NAME AGE GENDER CONTACT NUMBER DESIGNATION CURRENT RESIDENCE
(Surname, First Name, Middle Initial) (Street, Purok/Sitio, Zone, Barangay, Municipality)

10

11

12

13

14

15

16

17

18

19

20

Note: Please include all school personnel (include guard, utility, etc.)

Date Accomplished: RHU:

Division Nurse: RHU Covid Contact Person:
Contact No.
School Year:

COMORBIDITY MEDICATION/ TREATMENT

 NOVEL CORONAVIRUS (nCoV) SYMPTOM LOG

CATEGORY: DATE OF EXPOSURE:

NAME OF CLOSE CONTACT: DATE OF QUARANTINE PERIOD ENDS:

DATE DATE DATE DATE DATE DATE

SYMPTOM
(MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY)
No symptom

Fever (temperature)

Cough

Colds

Shortness of Breath

Difficulty of Breathing

Body Pain/Muscle Pain/Joint Pain

Other Symptom:

Actions done by NOD

Prepared by:
____________________________________________
AVIRUS (nCoV) SYMPTOM LOG SHEET

PROVINCE:
TINE PERIOD ENDS:

DATE DATE DATE DATE DATE DATE DATE DATE

(MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY)
 District/Cluster

Residence Nature and Date Date

CATEGORY (Other
Address of Last Quarantine
PUM - with exposure to
DATE Exposure Period Ends
Covid area, Close contact Known Medical
CONTACTED (Building, Age Sex Pregnant (Workplace, (mm/dd/yyyy)
No. to confirmed case,
/REPORTED (Start
Last Name First Name Middle Name School
Street, (years) (M/F)
Contact No.
(Y/N)
Civil Status Conditions/Medical
household, or 14 days post-
Suspect, Probable, History
of monitoring) Purok/Sitio, other public exposure or
Confirmed) N/A
Zone, area) until without
if not Covid case
Municipality) symptoms

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Prepared________________________________________________
by:
Week: ___________________________________
 Weekly basis monitoring/update for non - Covid 19 cases, Daily monitoring for Covid - 19 cases (Close con

Agencies Where
Date First
Rsponsible for Quarantined Laboratory Results
Asympt Sign/ Sign
Monitoring (Home/ Date Admitted Name of Referral (dates specimen
(DepEd nurse, Quarantine
omatic Symptom /Symptom Actions Taken
/Consulatation Facility taken and result Date Date Date Date Date Date Date
(Y/N) Developed Present
RHU, BHERT) Facility/Hospital released)
(mm/dd)
Pls specify )
d 19 cases, Daily monitoring for Covid - 19 cases (Close contact, Suspect, Probable, Confirmed)

Date Date Date Date Date Date Date