Republic of the Philippine

Department of Education
Region III – Central Luzon
Schools Division of Tarlac Province
San Jose West District
MAAMOT INTEGRATED SCHOOL
ELEMENTARY DEPARTMENT
San Jose, Tarlac
SY. 2021-2022

SCHOOL COVID RESPONSE

LIMITED FACE-TO-FACE COVID REFERRAL
FLOWCHART
SY 2021 – 2022

PREPARED BY:

JOVIELYN E. PASCUAL
ADVISER

NOTED

AMALIA C. TABAN
SCHOOL HEAD
 Republic of the Philippine
Department of Education
Region III – Central Luzon
Schools Division of Tarlac Province
San Jose West District
MAAMOT INTEGRATED SCHOOL
ELEMENTARY DEPARTMENT
San Jose, Tarlac
SY. 2021-20212

HEALTH DECLARATION FORM

Full Name (Buong Pangalan): Date {Petsa) (MM/DD/VY) :

Time {Oras):

Complete Current Address (Kasalukuyang tirahan):

Mobile/Phone Number {Numero ng telepono)

Email Address:

Put a check mark on the appropriate column of your response. (Lagyan ng tsek sa angkop na sagot.)

Yes No
(Oo) (Hindi)

1. Are you experiencing or a. Fever (Lagnat)

did you have any of the b. Cough and/or Colds (Ubo at/o Sipon)

following in the last 14 c. Body pains (Pananakit ng katawan)

days? {lkaw ba ay may
d. Sore Throat (Pananakit o pamamaga ng /alamunan)
nararanasan o nakaranas
e. Fatigue/Tiredness (Pagkapagod)
ng mga sumusunod na
f. Headache (Pananakit ng ulo)
sintomas sa nakaraang 14
g. Diarrhea (Pagtatae)
na araw?) h. Loss of taste or smell (Nawalan ng panlasa o pang-
amoy)

i.Difficulty of breathing (Pagkahapo o hirap sa pag

hinga)

2. Have you had face-to-face contact with a probable or confirmed COVID-19 case within 1 meter and for
more than 15 minutes for the past 14 days? (May nakasalamuha ka ba na maaaring o kumpirmadong
pasyente na may COV/D-19 mu/a sa isang metrong distansya or mas malapit pa at tumagal ng mahigit
15 minuto sa nakalipas na 14 araw?)

3. Have you provided direct care for a patient with probable or confirmed COVID-19 case without using
proper "Personal Protective Equipment (PPE)" for the past 14 days? (Nag-alaga ka ba ng maaring o
kumpirmadong pasyente na may COV/D-19 ng hindi nakasuot ng tamang PPE (Personal Protective
Equipment) sa nakalipas na 14 araw?)

4. Have you traveled outside the Philippines in the last 14 days? (lkaw ba ay nagbiyahe sa labas ng
Pilipinas sa nakalipas na 14 na araw?)

5. Have you traveled outside the current city/municipality where you reside?
{lkaw ba ay nagbiyahe sa labas ng iyong lungsod/munisipyo?) If yes, specify
which city/municipality you went to (Sabihin kung saan)

I hereby certify that the information given is true, correct and complete. I understand that failure to answer any
question or any falsified response may have serious consequences. I understand that my personal information is
protected by RA 10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from
the date of accomplishment, following the National Archives of the Philippines protocol.

Signature (Lagda): __________________________________

HEALTH DECLARATION CHECKLIST

IMPORTANT REMINDER: The information gathered on this form will be used only to determine whether you
may be infected with COVID-19. The information on this form is strictly confidential.
FILL OUT ENTRIES IN BOLD LETTERS

PERSONAL DATA:

Name: ________________________________________________________________________

Last name First name Middle name

Sex: ( ) Male Age: ____ Nationality: __________ Civil status: ______________

( ) Female

Contact Address: _________________________________________________________________________

(House No. and street) Barangay (Town/district)

___________________________________________________________________________________

(City/province) (Country) (Postal/Zip code)

Telephone No./Mobile No.: _________________ Email address: _________________________

Please check if you have any of the following at present or during the past 14 days:

( ) fever >37.5 C ( ) sore throat ( ) diarrhea

( ) cough ( ) headache ( ) body aches

( ) difficulty of breathing ( ) loss of smell or taste. ( )colds/runny nose

) body weakness ( ) fatigue ( ) nausea/vomiting

Please enumerate, if any, cities in the Philippines you have lived, worked, transited in the past 14 days

__________________________________________________________________________________________

Please enumerate, if any, foreign countries you have lived, worked, transited in the past 14 days

__________________________________________________________________________________________
Please check the appropriate box:

In the last 14 days, have you been in close contact or exposed ( ) Yes ( ) No

to any person suspected of COVIDS-19?

Were you confined in a hospital/health care facility during the ( ) Yes ( ) No

past 14 days?

Have you been diagnosed to have pneumonia in the past 14 days? ( ) Yes ( ) No

Did you visit any health facility, hospital or clinic in the past 14 days? ( ) Yes) ( ) No

Do you have any household member/s or close contact/s who are currently
having fever, cough, or any respiratory problems? ( ) Yes ( ) No

In the last 14 days, have you been in contact with a COVID-19 ( )Yes( ) No confirmed person?

When did this contact or person tested positive for RT-PCR? __________________________

Have you undergone any test for SARS-COV2 for the past 14days? ( ) Yes ( )No

Test Type:

[ ]RT-PCR []Rapid serologic antibody test

[ ] Gene expert [] Rapid Antigen Test

[ ] Others, specify ____________

Result:

[ ]positive [ ] Negative []Reactive [ ]Non-reactive

[ ]sample unfit for testing [ ]Pending

Where was the test done? ___________________ Date of release: _______________________