Room #: _____

Seat #: _____
Temp: _____

Annex “A3”

Post Examination Health Surveillance Form

Instructions: Please continue to follow social distancing and the wearing of face mask even
after the exam. You are required to send an email to the official email address of the
Regional Office where you took your licensure examination 15 days after the last
examination date. Please provide truthful information relative to your health status.
FOR PRC XII – Koronadal City:
Please send the accomplished this Annex A3 to: health.prc12@gmail.com
ON

Dear PRC,

Good day! I took the licensure examination last

(Profession)

. I would like to inform you of my health status as of

(Date/s of Examination)

:
(Date)

Name: ______________________________________________

Testing Venue: _________

Room No: _________

Seat No: _________

My health status is I (Please check all relevant items)

___ have no symptom/s.
___ am with the following symptom/s:
___ fever
___ cough
___ easy fatigability
___ other signs/ symptoms or remarks: ___________

After completing the message, you will receive an acknowledgment and/or further instructions
from PRC.

Thank you for your cooperation and STAY SAFE.