REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF AGRARIAN REFORM

Tunay na Pagbabago sa Repormang Agraryo

CHECKLIST ON PROTOCOLS UNDER DAR M.C 15 -2020

FORM No. 1

INTRUCTIONS: Please accomplish this Checklist which serves as guide for

complying with the protocols under the Memorandum Circular which you should
have read by now. Submit this report to the next higher office. Please print or
write legibly. Please initial every page.

NAME POSITION

1. HEAD OF OFFICE AUGUSTO M. DELLOSA ______MARPO______

2. PROTOCOL COMMITTEE

2.1. _____________________ ___________________

2.2. _____________________ ___________________
2.3. _____________________ ___________________
2.4. _____________________ ___________________
2.5. _____________________ ___________________
2.6. _____________________ ___________________
2.7. _____________________ ___________________
2.8. _____________________ ___________________
2.9. _____________________ ___________________
2.10. _____________________ ___________________
2.11. _____________________ ___________________
2.12. _____________________ ___________________
2.13. _____________________ ___________________
2.14. _____________________ ___________________
2.15. _____________________ ___________________

3. PHYSICAL PLANT

3.1. Address: SAN PEDRO, IROSIN, SORSOGON .

3.2. No. of Bldgs ______ONE(1)______________________
3.3. No. of Floors/Bldg ____TWO(2)________________________
3.4.Approx. Area of Open Grounds _____4 SQUARE METERS___________

Certified True and Correct: (SIGNED) AUGUSTO M. DELLOSA

DAR CENTRAL OFFICE TEL. NO. 34538566

 CHECKLIST ON PROTOCOLS UNDER DAR M.C 15 -2020
FORM No. 1

Elliptical Road, Diliman, Quezon City WEBSITE: www.dar.gov.ph

4. CHECKLIST FOR PROTOCOLS YES NO EXPLAIN NON-COMPLIANCE

4.1. Grounds Cleaned __ _____ ____________________________

4.2. Grounds Disinfected __ _____ ____________________________

4.3. Bldgs Cleaned __ _____ ____________________________

4.4. Bldgs Disinfected __ _____ ____________________________

4.5. Offices Cleaned __ _____ ____________________________

4.6. Offices Disinfected ______ ___________________________

4.7. Toilets Disinfected __ _____ ____________________________

4.8. Pest Control __ _____ ____________________________

4.9. Files Cleaned __ _____ ____________________________

4.10. Files Disinfected __ _____ ____________________________

4.11. Books Cleaned __ _____ ____________________________

4.12. Books Disinfected __ _____ ____________________________

4.13. Furniture Cleaned __ _____ ____________________________

4.14. Furniture Disinfected __ __ _ _________________________________

4.15. Equipment Cleaned __ _____ ____________________________

4.16. Equipment Disinfected __ __ __________________________________

4.17. Plastic Cover Eqpt. Etc. __ _____ ____________________________

4.18. Running Water OK __ _____ ____________________________

4.19. Electric Power OK __ _____ ____________________________

4.20. Air Conditioning OK __ _____ ____________________________

4.21. Computers OK __ _____ ____________________________

4.22. Internet OK __ _____ ____________________________

Certified True and Correct: (SIGNED) AUGUSTO M. DELLOSA

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 CHECKLIST ON PROTOCOLS UNDER DAR M.C 15 -2020
FORM No. 1

4.23. LAN OK __ _____ ____________________________

4.24. CPhone Cards OK ____ ___ __________

4.25. 2 WAY Radio OK ____ __ not available____________

4.26. Visitors Lounge OK __ _____ ____________________________

4.26. Receiving Rm OK __ _____ ____________________________

4.27. Isolation RM OK __ _____ ____________________________

4.28. Disinfectants OK __ _____ ____________________________

4.29. Alcohol OK __ _____ ____________________________

4.30. Soap OK __ _____ ____________________________

4.31. Face Masks

Frontliners __ _____ ____________________________

All Personnel __ _____ ____________________________

4.32. Thermal Scanners

Shuttle Service ____ __ not available____________

Main Entrance
Offices @Provincial office __ _____ ____________________________

4.33. Shuttle Service OK ____ __ available_in the provincial

office only
4.34. Monitoring Team
Created OK ___ __ __ _____________________________

Oriented OK ___ __ _ _____________________________

4.35. Directional Signs _ _____ ____________________________

4.36. Instructional Posters _ _____ ____________________________

4.37. Visitors Pass _ ___ __ not available_at the municipal

office
4.38. Misting Stations
For Vehicles ____ __ not available____________

Certified True and Correct: (SIGNED) AUGUSTO M. DELLOSA

Page 3 of 6
 CHECKLIST ON PROTOCOLS UNDER DAR M.C 15 -2020
FORM No. 1

4.39. Health Decla

Form Ready ____ __ not available____________

4.40. PPE Isolation Room

for Frontliners: ____ _____ ______Not applicable__________
Gowns ____ __ not applicable____________
Masks __ _____ ____________________________
Face Shields __ _____ ____________________________
Gloves __ _____ ____________________________

4.41. PPE Visitors Room

and Receiving Room ____ ___ not available____________
for Frontliners: ____ ___ not available____________
Masks ____ ___ available at office
DARMO___________
Face Shields ____ ___ not available____________
Gloves ____ ___ not available____________

4.42. Trained Frontliners:

Visitors Lounge ____ ___ not applicable___________
Receiving Rm ____ ___ not applicable___________
Isolation Room ____ ___ not applicable___________

4.43. Physical Distancing:

Visitors Lounge __ _____ ____________________________
Receiving Rm __ _____ ____________________________
Isolation Rm ____ ___ not applicable__________
All Offices

4.44. Orient on MC 15:

Maintenance Chief ___ ____ ____________________________
Security Chief ____ ___ at the provincial office____
All Personnel __ _____ ____________________________
All Visitors __ _____ ____________________________

4.45. Posters Out Office

WEAR FACE __ _____ ___________________________
MASK
WEARDAR ___ _____ ___________________________
ID

CertifieCertified True and Correct:

(Signed) AUGUSTO M. DELLOSA

Page 4 of 6
 CHECKLIST ON PROTOCOLS UNDER DAR M.C 15 -2020
FORM No. 1

NO COMMUNAL MEALS __ _____ ___________________

NO GROUP MEETING __ _____ _______________________
NO LOITERING __ ____ ______________________
NO FACE TO FACE MEETS__ _____ ____________________
NO MASS GATHERING _ _____ ________________________
SOCIAL DISTANCE __ _____ ________________________
ALWAYS SANITIZE __ _____ ________________________
CONTACT TRACE _ ___ with logbook of visitors
KEEP THE FAITH __ _____ ________________________
WE RECOVER AS ONE __ ______________________

4.46. OPENED LINES:

LGU __ _____ ____________________________
DA __ _____ ____________________________
DSWD __ _____ ____________________________
DOH __ _____ ____________________________
PNP __ _____ ____________________________

4.47 PROPOSED WFH /AWA

SENT TO RD ____ _____ Working on full capacity at
DARMO level no WFH
SENT TO OSEC ____ _____ ____________________________

4.48. REPORT TO CSC REGL

ALL APPROVED __ _____ ____________________________
WFH/AWA ____ _____ ____________________________

5.0. MONITORING REPORT

5.1. Are there incidents of protocol breach of DAR MC 15-2020.

Briefly state: Who/What/When/Where/How/Why/Action Taken:

________________________ not applicable________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Is there any personnel of DAR who is currently being monitored, suspected or is actually
undergoing treatment for COVID-19 infection since the time when we commenced the general
community quarantine? What actions, if any, has the Protocol Committee taken.
_____- ____ / We are following the Health Protocol of the
DOH________________________________________________________________________
____________________________________________________________________________
.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

5.3. How is the morale and attitude of the DAR personnel in your office as we approach the
new normal? Are there any actions which you are taking on these matters?

Page 5 of 6
 CHECKLIST ON PROTOCOLS UNDER DAR M.C 15 -2020
FORM No. 1

DARMO personnel are religiously following_____the health

protocol_____________________________________________________________________
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Certified True and Correct: _______Signed________

AUGUSTO M. DELLOSA

CERTIFIED CORRECT FOR THE PROTOCOL COMMITTEE

NAME : AUGUSTO M. DELLOSA_________

SIGNATURE : ____________signed______________________
DATE : _________November 15, 2020______________

Please send this report to the next higher Office

MARPO please submit this report to the PARPO II on Mondays
PARPO II please submit this report to the Regional Director on Tuesdays
Regional Directors please submit this report to the USEC LAO on Wednesdays

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