Republic of the Philippines

Department of Education
Region 02 (Cagayan Valley)
Schools Division Office Of Isabela
Echague North Interim District
ECHAGUE EAST CENTRAL SCHOOL
San Fabian, Echague, Isabela 3309

Symptoms Observed/Reported
NAME Date: Date: Date: Date: Date:
Monday Tuesday Wednesday Thursday Friday

NOTE: As soon as any of the listed symptoms are observed among any of the learners, the teacher is expected to send the learner to the School Clinic immediately for the proper
management by the School Clinic Teacher or Health Personnel.

Submitted by: Noted by:

PRIMROSE EMERY C. EDADES EMILIA T. MESA

Classroom Adviser School Clinic Teacher
 Republic of the Philippines
Department of Education
Region 02 (Cagayan Valley)
Schools Division Office Of Isabela
Echague North Interim District
ECHAGUE EAST CENTRAL SCHOOL
San Fabian, Echague, Isabela 3309
Reporting, Management, and Referral

Date Time Name Age Sex Grade & Teacher Adviser Chief Doctor's Order [To be Treatment Administered By Remarks [Indicate how Follow-up Status [As
Admitted Section Complaint(s) initialed by the Medical the instructions of the needed; Date/Status]
[Reason(s) for Officer upon visit]/ doctor were followed,
the clinic Supported by the doctor's as well as other actions
visit/ reported Prescription/Instruction taken; e.g., ordered to
symptom(s)] Slip return to classroom,
what time; reported to
BHERT, specify contact
_ Administer number; informed the
treatment parent about
_ Contact the instructions, fetched
parents by; etc.]
_ Refer to health
facility
_ Report to BHERT

Submitted by: Noted by:

 Republic of the Philippines
Department of Education
Region 02 (Cagayan Valley)
Schools Division Office Of Isabela
Echague North Interim District
ECHAGUE EAST CENTRAL SCHOOL
San Fabian, Echague, Isabela 3309

PRIMROSE EMERY C. EDADES EMILIA T. MESA

Classroom Adviser School Clinic Teacher
SUMMARY OF HEALTH STATUS OF LEARNERS
NAME CATEGORY GRADE DATE SYMPTOM(S) ACTION TAKEN COVID-19 STATUS
(Personnel/ LEVEL/SECTION REPORTED Observed/Reporte (Referred to) per Follow Up
Leaner) d
1 Learner
2 Learner
3 Learner
4 Learner
5 Learner
6 Learner
7 Learner
8 Learner
9 Learner
10 Learner
11 Learner
12 Learner
13 Learner
14 Learner
15 Learner
16 Learner
17 Learner
18 Learner
19 Learner
20 Learner
FOR THE MONTH OF MAY

SUBMITTED BY:
Republic of the Philippines
Department of Education
Region 02 (Cagayan Valley)
Schools Division Office Of Isabela
Echague North Interim District
ECHAGUE EAST CENTRAL SCHOOL
San Fabian, Echague, Isabela 3309
PRIMROSE EMERY C. EDADES
NOTED BY: Class Adviser
EMILIA T. MESA
School Clinic Teacher
MAY GO HOME SLIP
Date:
Name
Age
Sex
Grade/Section
Teacher-Adviser

This certifies that the learner has been provided initial management at the clinic, with instructions from:
Name of Doctor:

The doctor has given instruction that the learner may go home/be fetched by his/her parent/guardian.
Signed:
Clinic Teacher/Nurse

This certifies that I have been provided important information/instructions by the clinic teacher/nurse:
Signed:

Name of fetcher:
Relation to the child:
Time fetched:
Present this May Go Home Slip and cut and leave the upper portion of the slip to the guard before leaving the school.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-
This lower portion may be brought home by the parent/fetcher.
REMINDERS TO THE PARENT
_ Please monitor the following:
_ Please consult with…
Republic of the Philippines
Department of Education
Region 02 (Cagayan Valley)
Schools Division Office Of Isabela
Echague North Interim District
ECHAGUE EAST CENTRAL SCHOOL
San Fabian, Echague, Isabela 3309
_ Your child has been reported to the BHERT ( __________________ ); please coordinate with them for the next steps
_ Please inform the school immediately if your child tests positive for COVID-19.
Other instructions:
_ Medical certificate/clearance is required before the learner is allowed to return to face-to-face classes, subject to the approval of the DepEd Medical
Officer