Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

REGION IV-A CALABARZON REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS SCHOOLS DIVISION OF BATANGAS
   
PERSONAL INFORMATION PERSONAL INFORMATION
FIRST FIRST
NAME NAME
MIDDLE MIDDLE
NAME NAME

SURNAME SURNAME

CURRENT CURRENT
ADDRESS ADDRESS
CONTACT CONTACT
NUMBER NUMBER
STATION STATION
SECTION SECTION

POSITION POSITION

HEALTH SURVEY HEALTH SURVEY

YES NO YES NO
1. Have you experienced for the last 14 days: 1. Have you experienced for the last 14 days:
Cough Cough
Colds Colds
Fever Fever
Sore Throat Sore Throat
Other sign and symptoms Other sign and symptoms

2. Current medical conditions (Eg. Diabetes, HPN, etc) 2. Current medical conditions (Eg. Diabetes, HPN, etc)

CLOSE CONTACT CLOSE CONTACT

YES NO YES NO

1. Have you provided or still providing care 1. Have you provided or still providing care
without personal protective equipment without personal protective equipment
(PPE) for COVID-19 patients? (PPE) for COVID-19 patients?

2. Have you traveled together in a close
proximity (1 meter or less) with a COVID-19
patient in any kind of transportation within
14-day period after the onset of symptoms?
3. Have you traveled together in a close
proximity (1 meter or less) with a COVID-19
patient in any kind of transportation within
14-day period after the onset of symptoms?
2. Have you traveled together in a close
proximity (1 meter or less) with a COVID-19
patient in any kind of transportation within
14-day period after the onset of symptoms?
3. Have you traveled together in a close
proximity (1 meter or less) with a COVID-19
patient in any kind of transportation within
14-day period after the onset of symptoms?

HISTORY OF COVID-19 HISTORY OF COVID-19

SUSPECT PROBABLE CONFIRMED NO SUSPECT PROBABLE CONFIRMED NO
1. Have you been 1. Have you been
considered as a considered as a
COVID-19 Suspect, COVID-19 Suspect,
Probable or Probable or
Confirmed in the last Confirmed in the last
14 days? 14 days?

TRAVEL HISTORY TRAVEL HISTORY

LIST THE PLACES YOU VISITED FOR THE LAST 14 DAYS LIST THE PLACES YOU VISITED FOR THE LAST 14 DAYS

DATE / TIME NAME / SIGNATURE DATE / TIME NAME / SIGNATURE