HEALTH CHECKLIST Temperature:

Name:
Sex: Age: Contact No:
Residence: _______________________________________________________________
Office/School: DNHS-HINDANG SCHOOL ANNEX
Office/School Address: Hindang, Iligan City
Mark (√) Please answer honestly. YES NO

1. Are you experiencing: a. Sore throat

b. Body pains
c. Headache
d. Fever for the
past few days
2. Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
3. Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
4. Have you travelled outside of the
Philippines in the last 14 days?
5. Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Clark Kent F. Batucan

Sex: Male Age: 30 Contact No: 09059739351
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

6. Are you experiencing: e. Sore throat

f. Body pains
g. Headache
h. Fever for the
past few days
7. Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
8. Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
9. Have you travelled outside of the
Philippines in the last 14 days?
10.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Brenda C. Berangel

Sex: Female Age: 44 Contact No: 09262208961
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

11.Are you experiencing: i. Sore throat

j. Body pains
k. Headache
l. Fever for the
past few days
12.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
13.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
14.Have you travelled outside of the
Philippines in the last 14 days?
15.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Raquel A. Figuracion

Sex: Female Age: 35 Contact No: 09261152966
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

16.Are you experiencing: m. Sore throat

n. Body pains
o. Headache
p. Fever for the
past few days
17.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
18.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
19.Have you travelled outside of the
Philippines in the last 14 days?
20.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Mitchell V. Gagarra

Sex: Male Age: 35 Contact No: 09268545675
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

21.Are you experiencing: q. Sore throat

r. Body pains
s. Headache
t. Fever for the
past few days
22.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
23.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
24.Have you travelled outside of the
Philippines in the last 14 days?
25.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Remen Jose B. Gumba

Sex: Male Age: 29 Contact No: 09358886217
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

26.Are you experiencing: u. Sore throat

v. Body pains
w. Headache
x. Fever for the
past few days
27.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
28.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
29.Have you travelled outside of the
Philippines in the last 14 days?
30.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Abigail O. Pondang

Sex: Female Age: 40 Contact No: 09066146473
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

31.Are you experiencing: y. Sore throat

z. Body pains
aa.Headache
bb. Fever
for the past
few days
32.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
33.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
34.Have you travelled outside of the
Philippines in the last 14 days?
35.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Jovanne B. Tatoy

Sex: Male Age: 29 Contact No: 09155641979
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

36.Are you experiencing: cc. Sore throat

dd. Body
pains
ee.Headache
ff. Fever for the
past few days
37.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
38.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
39.Have you travelled outside of the
Philippines in the last 14 days?
40.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Rowena M. Teofilo

Sex: Female Age: 27 Contact No: 09467117748
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

41.Are you experiencing: gg.Sore throat

hh. Body
pains
ii. Headache
jj. Fever for the
past few days
42.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
43.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
44.Have you travelled outside of the
Philippines in the last 14 days?
45.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Rene R. Ubarco

Sex: Male Age: 35 Contact No: 09755781058
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

46.Are you experiencing: kk. Sore throat

ll. Body pains
mm. Headach
e
nn. Fever for
the past few
days
47.Have you worked together or stayed
in the same close environment of a
confirmed COVID-19 case?
48.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
49.Have you travelled outside of the
Philippines in the last 14 days?
50.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Joshua Jordan N. Ventic

Sex: Male Age: 32 Contact No: 09107465426
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

51.Are you experiencing: oo. Sore

throat
pp. Body
pains
qq. Headach
e
rr. Fever for the
past few days
52.Have you worked together or stayed
in the same close environment of a
confirmed COVID-19 case?
53.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
54.Have you travelled outside of the
Philippines in the last 14 days?
55.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Ruth S. Talingting

Sex: Female Age: 51 Contact No: 09283102849
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

56.Are you experiencing: ss. Sore throat

tt. Body pains
uu. Headach
e
vv. Fever for the
past few days
57.Have you worked together or stayed
in the same close environment of a
confirmed COVID-19 case?
58.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
59.Have you travelled outside of the
Philippines in the last 14 days?
60.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________

HEALTH CHECKLIST Temperature:

Name: Charly B. Parmisana

Sex: Male Age: 25 Contact No: 09164594779
Residence: _______________________________________________________________
Office/School: ____________________________________________________________
Office/School Address: _____________________________________________________
Mark (√) Please answer honestly. YES NO

61.Are you experiencing: ww. Sore

throat
xx. Body pains
yy. Headache
zz. Fever for the
past few days
62.Have you worked together or stayed in
the same close environment of a
confirmed COVID-19 case?
63.Have you had any contact with fever,
cough, and sore throat in the past 2
weeks?
64.Have you travelled outside of the
Philippines in the last 14 days?
65.Have you travelled to any area with
confirmed local transmission? Specify
where: ________________

I hereby authorize the School Health Section of Deped Iligan City Division, to collect and
process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data
Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act,
to provide truthful information.

Signature: __________________________________ Date: ________________________