SAMPAGUITA ELEMENTARY SCHOOL

CONTACT TRACING FORM

PARENT/ GUARDIAN INFORMATION
Name (Person who returned the books): ___________________________________________________________
Address:______________________________________________________________________________________
Contact No:____________________________________________________________________________________
Last place visited:_______________________________________________________________________________
Are You experiencing any of the following?(Please check)
Cough________ Colds________ fever________ sore throught________ shortness of breath________
Have you been in contact with a COVID-19 positive/suspect in the past 14 days? YES____ NO_____
PUPILS INFORMATION
Name of Pupil:__________________________________________________________________________________
Grade Level /Section:_____________________________________________________________________________
Adviser: ________________________________________________________________________________________

SAMPAGUITA ELEMENTARY SCHOOL

CONTACT TRACING FORM
PARENT/ GUARDIAN INFORMATION
Name (Person who returned the books): ___________________________________________________________
Address:______________________________________________________________________________________
Contact No:____________________________________________________________________________________
Last place visited:_______________________________________________________________________________
Are You experiencing any of the following?(Please check)
Cough________ Colds________ fever________ sore throught________ shortness of breath________
Have you been in contact with a COVID-19 positive/suspect in the past 14 days? YES____ NO_____
PUPILS INFORMATION
Name of Pupil:__________________________________________________________________________________
Grade Level /Section:_____________________________________________________________________________
Adviser: ________________________________________________________________________________________

SAMPAGUITA ELEMENTARY SCHOOL

CONTACT TRACING FORM
PARENT/ GUARDIAN INFORMATION
Name (Person who returned the books): ___________________________________________________________
Address:______________________________________________________________________________________
Contact No:____________________________________________________________________________________
Last place visited:_______________________________________________________________________________
Are You experiencing any of the following?(Please check)
Cough________ Colds________ fever________ sore throught________ shortness of breath________
Have you been in contact with a COVID-19 positive/suspect in the past 14 days? YES____ NO_____
PUPILS INFORMATION
Name of Pupil:__________________________________________________________________________________
Grade Level /Section:_____________________________________________________________________________
Adviser: ________________________________________________________________________________________