Republic of the Philippines

Department of Education
REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OF ILOILO
DISTRICT OF POTOTAN I
BATUAN ELEMENTARY SCHOOL

PLEASE WRITE COMPLETE NAME DATE: _________________________________

PRINT FULL NAME SCHOOL/ PURPOSE/ TIME TEMP Are you experiencing any of the following? CP NO SIGN
ADDRESS DESTINATION IN X if NO and ̸ if YES
Loss Loss Diarrhea Cough Sore Body Head Fever COVID Close contact Travelled
of of throat Pain ache + close with outside of
taste smell contact symptomatic ILOILO/PH

Address: Luna St., La Paz, Iloilo City 5000

Tel./Fax No. (033) 320-1402 | (033) 320-0719 | (033) 320-0707 | (033) 327-2252
Website: http://www.depediloilo.ph | e-mail: iloilo@deped.gov.ph
PLEASE WRITE COMPLETE NAME DATE: _________________________________

PRINT FULL NAME SCHOOL/ PURPOSE/ TIME TEMP Are you experiencing any of the following? CP NO SIGN
ADDRESS DESTINATION IN X if NO and ̸ if YES
Loss Loss Diarrhea Cough Sore Body Head Fever COVID Close contact Travelled
of of throat Pain ache + close with outside of
taste smell contact symptomatic ILOILO/PH

Address: Luna St., La Paz, Iloilo City 5000

Tel./Fax No. (033) 320-1402 | (033) 320-0719 | (033) 320-0707 | (033) 327-2252
Website: http://www.depediloilo.ph | e-mail: iloilo@deped.gov.ph