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,
Republic of the Philippines
Department of Education
Region VI – Western Visayas
Schools Division of Iloilo
District of Pototan II
LUMBO ELEMENTARY SCHOOL

HEALTH DECLARATION SHEET Grade 1

S.Y. 2022-2023
DATE: ___________________

Check if you experience any of the following:

PRINT FULL NAME SCHOOL/ PURPOSE/ TIME
TEMP CP NO SIGN
ADDRESS DESTINATION IN Loss
of
Loss
of Diarrhea Cough
Sore
throat
Body
Pain
Head
ache
Fever
COVID +
close
Close contact
with
Travelled
outside
taste smell contact symptomatic

Address: Barangay Lumbo, Pototan, Iloilo

Email Address: 116667.iloilo@deped.gov.ph
Contact Number: 09466062501