TO BE FILLED OUT BY THE SDO COMPOSITE TEAM

YES NO
1. The school has secured the concurrence of the Local Chief Executive in the
City/Municipality where the school is located and must also have taken the
proper coordination with their respective barangay officials.

a. For schools in IP communities or with a predominant number of IP learners, the

Free, Prior, and Informed consent (FPIC) process must be undertaken according to
the customary practice of the IP community. The cultural expression of consent and
sealing of agreements shall be documented, with the permission of the community
and in a form acceptable to them (e.g. pictures, videos). Without prejudice to the
latter, a Certificate of Precondition issued by NCIP shall also attest to the undertaking
of the FPIC process and agreements reached.

2. The school has secured written consent from the parents/ guardians of
learners who will participate in the face-to-face classes.

No. of Participating Learners for the Expanded Face-to-Face: _________

No. of Parent’s Consent Collected:____________

3. Vaccination Status of School Personnel

No. of Vaccinated Teachers: ________

Total No. of Teachers: ______

No. of Vaccinated Non-Teaching Personnel: _________

Total No. of Vaccinated Non-Teaching Personnel: _________

Validated/Inspected by:

Jessele Mark Reyes Dra. Angelita Orenciano

RO/SDO DRRM Coordinator RRO /SDO Health Officer
(Signature over Printed Name) (Signature over Printed Name)

Reniel Patrick S. Tejidor Joel Mina

RO/SDO Planning Officer RO /SDO Engineer
(Signature over Printed Name) (Signature over Printed Name)

Mary Ann Batino Gregoria S. Atas

CLMD/CID Representative QAD EPS-in Charge/SDO Priv. School In-Charge
(Signature over Printed Name) (Signature over Printed Name)