Annex G Annex G Annex G

HEALTH FORM (Note: To be submitted 24 to 72 hrs. prior to the start of school Enclosure to DepEd Joint Memorandum Circular No. 01, s. 2021 on the
opening.) Operational Guidelines on the Pilot Implementation of Face-to-Face
HEALTH FORM Learning Modality
(Note: To be submitted 24 to 72 hrs. prior to the start of school
opening.)
I, _________________________________, declare HEALTH FORM
that my entire household was not considered a close
contact, suspect, probable, or confirmed COVID-19 I, _________________________________, declare
case the past 14 days. Further, we do not experience that my entire household was not considered a close
ant symptoms related to COVID-19 such as: contact, suspect, probable, or confirmed COVID-19
I, _________________________________, declare
a. Fever f. Fatigue/ Tiredness case the past 14 days. Further, we do not experience
that my entire household was not considered a close
b. Cough and Colds g. Headache ant symptoms related to COVID-19 such as:
contact, suspect, probable, or confirmed COVID-19
c. Difficulty of breathing h. Loss of taste or smell a. Fever f. Fatigue/ Tiredness
case the past 14 days. Further, we do not experience
d. Sore throat i. Body pains b. Cough and Colds g. Headache
ant symptoms related to COVID-19 such as:
e. Diarrhea c. Difficulty of breathing h. Loss of taste or smell
a. Fever f. Fatigue/ Tiredness
d. Sore throat i. Body pains
b. Cough and Colds g. Headache
I hereby certify that the information given is true, e. Diarrhea
c. Difficulty of breathing h. Loss of taste or smell
correct, and complete. I understand that any falsified d. Sore throat i. Body pains
response may have serious consequences. I I hereby certify that the information given is true,
e. Diarrhea
understand that my personal information is protected correct, and complete. I understand that any falsified
by RA 10173 or the Data Privacy Act of 2012 and that response may have serious consequences. I
I hereby certify that the information given is true,
this form will be destroyed after 20 days from the date understand that my personal information is protected
correct, and complete. I understand that any falsified
of accomplishment, following the National Archives of by RA 10173 or the Data Privacy Act of 2012 and that
response may have serious consequences. I
the Philippines protocol. this form will be destroyed after 20 days from the date
understand that my personal information is protected
of accomplishment, following the National Archives of
by RA 10173 or the Data Privacy Act of 2012 and that
the Philippines protocol.
this form will be destroyed after 20 days from the date
_________________________ _____________ of accomplishment, following the National Archives of
Name and Signature Date the Philippines protocol.
_________________________ _____________
Name and Signature Date
_________________________ _____________
Enclosure to DepEd Joint Memorandum Circular No. 01, s. 2021 on the Name and Signature Date
Operational Guidelines on the Pilot Implementation of Face-to-Face
Learning Modality
Annex G Annex G Annex G
Enclosure to DepEd Joint Memorandum Circular No. 01, s. 2021 on the
Operational Guidelines on the Pilot Implementation of Face-to-Face
Learning Modality
(Note: To be submitted 24 to 72 hrs. prior to the start of school
opening.)