NAME ADDRESS TEMP SEX CONTACT # 1.Are you experiencing: 2.Have you 3. Have you had 4.

ve you 3. Have you had 4. Have you 5.Have you Signature

ERAT Worked any contact with travelled travelled to
URE together or anyone with outside the any area in
stayed in the fever,cough,cold Philippines Pangasinan
same close s and sore throat in the last aside from
environment in the past 2 14 days? your
of confirmed weeks? Home?
COVID-19
case?
A. B. C. D.
Sore Body Head Fever
throat Pain ache
Y N Y N Y N Y N YES NO YES NO YES NO YES NO
E O E O E O E O
S S S S
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Prepared By: ___________________ Checked By: Felina I. Ramos
Noted By: ENGR. Florentina I. Ramos
Adviser Head Teacher III OIC, Office of the Principal