Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

Region X Region X
School Division of Misamis Occidental School Division of Misamis Occidental
UPPER BAUTISTA PRIMARY SCHOOL UPPER BAUTISTA PRIMARY SCHOOL

HEALTH CHECKLIST / DECLARATION FORM HEALTH CHECKLIST / DECLARATION FORM

Temperature: ______________ Temperature: ______________

Name: Age: Name: Age:

Address: Sex: Address: Sex:

REMINDERS:
 Observe social distancing at least 1 meter.
 Handwashing station/ alcohol dispenser in strategic location
 Accomplish questionnaire/ Health Checklist upon entering the premise
 Use personsal pens or use sanitizers before and after using provided pens.
 No mask, No Entry Policy
REMINDERS:
 Observe social distancing at least 1 meter.
 Handwashing station/ alcohol dispenser in strategic location
 Accomplish questionnaire/ Health Checklist upon entering the premise
 Use personsal pens or use sanitizers before and after using provided pens.
 No mask, No Entry Policy

Instructions: Check (/) if YES or NO for each item provided , if there YES NO Instructions: Check (/) if YES or NO for each item provided , if there YES NO
is any is any
Before coming to school today, did you experience flu-like Before coming to school today, did you experience flu-like
symptoms like: symptoms like:
a) Body Pain a) Body Pain
b) Headache b) Headache
c) Cough c) Cough
d) Sore Throat
e) Fever in past 14 days
d) Sore Throat
f) Close contact with Covid-19 patients e) Fever in past 14 days
g) Travel outside the Philippines f) Close contact with Covid-19 patients
h) Travel to Ozamis City g) Travel outside the Philippines
i) Travel to any area in the NCR or other h) Travel to Ozamis City
Regions where Covid-19 cases are confirmed.
i) Travel to any area in the NCR or other
If you have any of the following symptoms , you are not allowed to enter the school. Please
Regions where Covid-19 cases are confirmed.
be advise to go to your healthcare provider for consultation. If NONE , you can enter the
If you have any of the following symptoms , you are not allowed to enter the school. Please
school to proceed with your transaction.
be advise to go to your healthcare provider for consultation. If NONE , you can enter the
Declaration and Data Privacy Consent Form:
school to proceed with your transaction.
The information I have given is true, correct and complete. I understand that failure to answer
any question or giving false answer can be penalized in accordance with law.
Declaration and Data Privacy Consent Form:
I voluntarily and freely consent to the collection and sharing of the above personal information
The information I have given is true, correct and complete. I understand that failure to answer
only in relation to the HRep COVID - 19 internal protocols.
any question or giving false answer can be penalized in accordance with law.
I voluntarily and freely consent to the collection and sharing of the above personal information
Name and Signature Date
only in relation to the HRep COVID - 19 internal protocols.
Please be advised that the above information shall be used in relation to the HRep
COVID - 19 internal protocols in accordance with the Data Privacy Act. For any concerns, Name and Signature Date
you may contact secretary.general@house.gov.ph
Please be advised that the above information shall be used in relation to the HRep
COVID - 19 internal protocols in accordance with the Data Privacy Act. For any concerns,
you may contact secretary.general@house.gov.ph