Republic of the Philippines

Province of Camarines Sur

MUNICIPALITY OF CARAMOAN

COVID-19 ARD SURVEILLANCE FORM

For Balikbayan/Tourist (Local and Foreign)

To be filled up by BHERT
Barangay Name of Investigator Date of Investigation

Last Name First Name Middle Name Age Sex

Address Phone/Cell Num:

Occupation Civil Status Nationality Educational Attainment

History of Travel/visit/work in other countries with in the last 30 days: Date of arrival in the Philippines:
Yes ( ) No ( )
Countries Visited/Traveled/Worked in During the last 14 days:
China ( ) Hong Kong ( ) Macau ( ) Other ( ) Specify:
History of exposure to known CoVid-19 ARD Case: YES ( ) NO ( )

Monitoring: 14 days Self Confinement at Home of Facility __________________________________________________

Date Captured: ____________________________________

*Temperature Monitoring *Signs and Symptoms

Days Date AM PM
1 Date of Onset
2 Fever ( )
Cough ( )
3
Shortness of ( )
4
Breath ( )
5
Difficulty of ( )
6
Breathing ( )
7 Body ( )
8 Weakness ( )
9 Muscle Ache ( )
10 Diarrhea ( )
11 Rash ( )
12 Others: ________
13
14

*Please report immediately in Temperature in ≥38C or with cough or other respiratory symptoms.

Date Reported: __________________________

Action Taken: __________________________________________________________________________________________