TALIKTIK INTEGRATED SCHOOL TALIKTIK INTEGRATED SCHOOL

Taliktik, Cordon, Isabela Taliktik, Cordon, Isabela

RISK ASSESSMENT CHECKLIST TOOL RISK ASSESSMENT CHECKLIST TOOL

Information Sheet: Information Sheet:

Name: ________________________ Age: _____ Name: ________________________ Age: _____
Address: __________________ CP No.: ________ Address: __________________ CP No.: ________
Temperature: __________ Signature: ________ Temperature: __________ Signature: ________

1. Have you experience any of the following 1. Have you experience any of the following
for the past few days? for the past few days?

YES NO YES NO

Loss of smell Loss of smell

Loss of taste Loss of taste

Fever / Flu Fever / Flu

Cough / colds Cough / colds

2. Did you travel outside 2. Did you travel outside

the province? the province?

3. Place recently visited 3. Place recently visited

______________________________ ______________________________

TALIKTIK INTEGRATED SCHOOL TALIKTIK INTEGRATED SCHOOL

Taliktik, Cordon, Isabela Taliktik, Cordon, Isabela
RISK ASSESSMENT CHECKLIST TOOL RISK ASSESSMENT CHECKLIST TOOL

Information Sheet: Information Sheet:

Name: ________________________ Age: _____ Name: ________________________ Age: _____
Address: __________________ CP No.: ________ Address: __________________ CP No.: ________
Temperature: __________ Signature: ________ Temperature: __________ Signature: ________

1. Have you experience any of the following 1. Have you experience any of the following
for the past few days? for the past few days?

YES NO YES NO

Loss of smell Loss of smell

Loss of taste Loss of taste

Fever / Flu Fever / Flu

Cough / colds Cough / colds

2. Did you travel outside 2. Did you travel outside

the province? the province?

3. Place recently visited 3. Place recently visited

______________________________ ______________________________