Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OF PANGASINAN II
ASAN SUR ELEMENTARY SCHOOL
Asan Sur, Sison, Pangasinan

TRIAGE CLEARANCE FORM

Triage Clearance is issued to ________________________________________
(Name of Client)
from ______________________________________ was examined at the Triage Area
(Name of School / District)
on _______________________.
(Date/Time of Examination)

__________________________
Teacher / BHW on Duty

________________________ __________________________
Health Officer Asst. Health Officer

Instructions:
 Wear complete uniform with ID.
 Always wear face mask and face shield (if needed).
 Wash your hands, spray with 70% alcohol or hand sanitizer.
 Proceed to self-thermal scanning.
 Fill up health declaration form in the Triage Area.
 Declare if FULLY VACCINATED

PARTIALLY VACCINATED

UNVACCINATED Reason: ___________

 Attach your transmittal form.
 Present this Triage Clearance Form to office/classroom you’re having transactions.
 Observe physical distancing at all times.
 Limit office transactions 1 to 2 persons at a time.

KEEP SAFE AND BE PROTECTED!