Version 2.

torm smll bs comdsted bY tho or are tfucru0ro lN TliE LIMITED

FACE.TO.FACE CITSSES ONLY.

of the sctpol opening and as the need adses' fiyour child is nd

feellng
Pleese $ilnit thi$ 24 trure pior to the $E t
*ifi}i*V OrV of {na week, ill out thiE form so your chfld will be considered excused from h'dher dasses.

This willbe of yer child's medical rewd ard wifl be treated wilh utmoet

Grade Lerel: $ectiofi:

Address , -
Coritact l,lumberrb; -
- (Mga YES
Sym$oms sk{omas)
1. 1. ls iutr chitd curenllY {oo)
exgefadng or had a.
exp,edetced the folio,viitg of sa paghinga)
Bymptc{ns ttithin 14 days?
c.
(Ksahkuyan bang
d. Headaeha {Pananakit t'g uh)
nakakaranas o n*arailas sr na
e,
ans iyoilg anak IE ngg 0
cf
sumusumd na sintom* 3a
g. CG4tr andl$ cold (Ubo aro sipon)
bob ng 14 na are#$
Dlanhaa
ycurcHd $l sam8 urith a

c,ovls19 case? (May naksssna ba ang iyong anak 0 nak#abahong tao na kumpirmadong
covlcFls
Ir€mber wfo r,raitirE for
lo y(x, a
(An-{ iyong anak bs E tltey kasama sa bahay na na*aantaY ns lesulla fs swab tesU cs/lsis
I

dtasie 0f
4. iisyou, expeeed to any pe$on with fever, cCIugh, cdds, sole throat,
may h$st, ubo, sipoo
smelt in the pst 2 *eekE? (MaP'oon bang naiesama ang iyoiU anak TE
sakt lalamunan sa
your kavel hsl 11 days? anak ba ay

sa hlas na t4 ne
Funher are
uder oath rhat p€rsofiany
peiinenl larrs, rubs, and egulathns oi tlE RepuHic of the
hje, csrect, and cernflete statemenh pursuant to th€ po&ions ot
Fhilippines.

dda lrdicaled herain fot he ptrpose of

I ?nreby arllroize pAto MTI ofitAt HlGll scltooL (PNHS) to msect and pr*ss lhe
i underdand hal tre perwralinfonmtion of my chfi'n prdec't*i by M t0173' B|a
efedingcwrtrol of tre COVlDtg infecliofi.
to piovil€
privacy Act of 2012, and lhd I ffi rsquir€d by RA le. 1't469, BayanilBn b l'hd as orE Act a5 amended by P'A 114S4,
thi iahe informatbn may hare seriors pbfic tealth impications md may be
trulilul inforrnation. FurtEr, I un&rstand any

subiected h legl co6equenres. Finally, I undersard tt6t in case my child

ririlltet pos{ive foi Oovid'l9 des$te this healttt
*chr*kx, PfifS Ail,a LCUmarart,.y concarcd shd povide fie n€cessery infdmation d ry dli6 for contad
upon requrct
trachg.

orrer Pthted lhro,e:

Versicn 2.0

ftrig iomr stnll be (ompletad by ttve PNNEUiIOUNNOIAN OF LEARNERS $/ho ft INCLUOED IN THE LIMITED

FACE.TO-FACE CLASSES ONLY,

sktt ol the sclpol opening and at th nesd adsee' ll yor child b not feellng
Please submit lhis 24 hours PioI to the
exoused kom his/tu dasses'
;1ffi *y ;;y;f h" weex, ill or.rt tNs fonn so your ohild will be considered
This willhc parl of medical rewd ard will be treatod with utm06t oonfidentidity'
Yur child's
Bd6:
Grde Lanl: ".- $ec'tim:

YES
1.lsyrurchH cunei{lY Symsons lldga sintonas) (ooi
1.
e4edencing a had
expaiarced the foliorhg
BFllptc{rlE $ithin 14 days?
- c.
iKasatukuyan bng C. lieadEchs (Panan*it ng uh)
nakakaranas o nakargtas M na
e. few
ang iymg arnk ng nga o
dtaste cr
sumusunod na siilonus sa
an#or a1!o
loob ng 14 na aaM)
h. clarhea
,#ith
yourclild or stayad m sams
case? (May nakasama bE ang iyong anak 0 r,akd.rabahorg tao krsnpirnadong
@vls19
covlDl9
3. y(x, a msrber ttfp raiting
(A,rS iyflrS anak ba ay m€y kmama sa bahay na nagiaantay ns rcsulta f€ surab test/ covls'r9
I

dtast€ 0f
4. li*
yc.lt expeed to aly pefson with fevet, c6jgh, cdds, sorc throat,
may la$at, ubo, sipdr 0
smell h lhe pa$ 2 ueeks? (Mayroan bsng nahasama anE iyong anak Bil
sakt lalamunan sa
your travel Philippines tie ht 14 *nak ba ay
sa labas nai4 *a
Furlher rhd ihe given se
urder oath personeHY this i{eaHh
to prrisions of peilinent larts, rubs, ard raplations of $ts Republic of the
tue, coned, and csn&te statemeilts pursuant th€

Fhilipines.

fo he purpose of
I tlaEby adhoriz€ PALO MTlo|,lAL HlGil SCHOOL (PNHS) to cdect and process fte &ta indicaled herain
f'al rte pem{dinhfioetkn dmy child is prdeded by RA 10173, Dda
Bffe.tingcoflhd oltre coYl&!9 infee,tlon. i wdersiand
Privacy of 20'12, and thd i an required by RA t'10' 1146e, tsayanitEn b
M lled as One Ad as anended by RA l'149{' tc pmvile l

truthful informathn. Furfiler, ! understand thd any false ilrionnatbn may

twe seriors prblic teallh imscations ad may be
*li*t* to r.g.r .*s€quenoes. Firdy, I uruier$tard tnt in case my child wfl tet postivo for foviiil9 despite hb healtlt

Uechrdkx, mtfs gpon raqusst A me LOUmar*nPy cucemed si6i prov[e tip necessaly inl€rmatlm d nry dliH fsr co6ct

tracing.

over Prhled Name: