Control No.

__________

Work from Home Medical Certificate for Vulnerable sectors

This is to certify that ___________________________, __________, _______________

(Complete Name) (Age/Sex) (Position)
of _______________________________________________ was diagnosed of having an
(Name of School/ Office)
illness and/or pre-existing medical condition as shown below;

o Cancer
o Chronic Lung Disease
a. Chronic Obstructive Pulmonary Disease (COPD)
b. Asthma (Moderate to Severe)
c. Interstitial Lung Disease
d. Cystic Fibrosis
e. Pulmonary Hypertension
o Dementia or other neurological conditions
o Diabetes Type I & 2
o Heart conditions
a. Heart failure
b. Coronary Artery Disease
c. Cardiomyopathies
d. Hypertension
o HIV infection
o Immunocompromised state
o Liver Disease (i.e. Liver cirrhosis)
o Obesity (BMI >30kg/m2)
o Pregnancy
o Hemoglobin & other blood disorders
o Solid organ or blood stem cell transplant
o Stroke or Cerebrovascular Disease
o 65 years old and above
o Others: ______________________
Remarks:
________________________________________________________________________________________________________
______________________________________________________________________________________This certification
is being issued for his or her request for Work From Home in reference to Division Memorandum No.
________

But may report on site as needed with strict compliance to minimum health safety protocols.

Recommending Approval:

JAY ANN L. PLAZA, MD

Medical Officer III Approved:

EUFEMIA T. GAMUTIN, CESO V

Schools Division Superintendent