HEALTH DECLARATION CHECKLIST

NAME:__________________________ DATE:________________ TIME:___________________

ADDRESS:_______________________________________________________________
CELL NUMBER:_____________________________________________AGE:________________
NAME OF STUDENT:_____________________GRADE:_________ SECTION:________________

MERON KA BANG NAG TRAVEL KA BA SA MGA

NARARAMDAMAN SA KASALUKUYAN?LUGAR NA MAY COVID? SAAN?
Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES

SIPON OO
UBO HINDI
UBO/SIPON ADDRESS:
UBO/HIRAP HUMINGA
HIRAP HUMINGA
LAGNAT/TEMPERATURE_____
WALA

HEALTH DECLARATION CHECKLIST

NAME:__________________________ DATE:________________ TIME:___________________

ADDRESS:_______________________________________________________________
CELL NUMBER:_____________________________________________AGE:________________
NAME OF STUDENT:_____________________GRADE:_________ SECTION:________________

MERON KA BANG NARARAMDAMAN NAG TRAVEL KA BA SA MGA LUGAR NA MAY

KASALUKUYAN? Pakilagyan ng tsek COVID? SAAN? PAKILAGAY ANG ADDRESS
kung meron

SIPON OO
UBO HINDI
UBO/SIPON ADDRESS:
UBO/HIRAP HUMINGA
HIRAP HUMINGA
LAGNAT/TEMPERATURE_____
WALA
 HEALTH DECLARATION CHECKLIST HEALTH DECLARATION CHECKLIST

NAME:___________________ DATE:__________ TIME:_______ NAME:___________________ DATE:__________ TIME:_______

GRADE:____ SECTION: ___________ AGE: ______ STUDENT ( ) GRADE:____ SECTION: ___________ AGE: ______ STUDENT ( )
CELL NUMBER:___________________ PARENT/GUARDIAN ( ) CELL NUMBER:___________________ PARENT/GUARDIAN ( )
ADDRESS: ________________________________ VISITOR ( ) ADDRESS: ________________________________ VISITOR ( )

MERON KA BANG NAG TRAVEL KA BA SA MGA MERON KA BANG NAG TRAVEL KA BA SA MGA
NARARAMDAMAN SA KASALUKUYAN? LUGAR NA MAY COVID? SAAN? NARARAMDAMAN SA KASALUKUYAN? LUGAR NA MAY COVID? SAAN?
Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES

SIPON OO SIPON OO
UBO HINDI UBO HINDI
UBO/SIPON ADDRESS: UBO/SIPON ADDRESS:
UBO/HIRAP HUMINGA UBO/HIRAP HUMINGA
HIRAP HUMINGA HIRAP HUMINGA
LAGNAT/TEMPERATURE_____ LAGNAT/TEMPERATURE_____
WALA WALA

HEALTH DECLARATION CHECKLIST HEALTH DECLARATION CHECKLIST

NAME:___________________ DATE:__________ TIME:_______ NAME:___________________ DATE:__________ TIME:_______

GRADE:____ SECTION: ___________ AGE: ______ STUDENT ( ) GRADE:____ SECTION: ___________ AGE: ______ STUDENT ( )
CELL NUMBER:___________________ PARENT/GUARDIAN ( ) CELL NUMBER:___________________ PARENT/GUARDIAN ( )
ADDRESS: ________________________________ VISITOR ( ) ADDRESS: ________________________________ VISITOR ( )

MERON KA BANG NAG TRAVEL KA BA SA MGA MERON KA BANG NAG TRAVEL KA BA SA MGA
NARARAMDAMAN SA KASALUKUYAN? LUGAR NA MAY COVID? SAAN? NARARAMDAMAN SA KASALUKUYAN? LUGAR NA MAY COVID? SAAN?
Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES

SIPON OO SIPON OO
UBO HINDI UBO HINDI
UBO/SIPON ADDRESS: UBO/SIPON ADDRESS:
UBO/HIRAP HUMINGA UBO/HIRAP HUMINGA
HIRAP HUMINGA HIRAP HUMINGA
LAGNAT/TEMPERATURE_____ LAGNAT/TEMPERATURE_____
WALA WALA

HEALTH DECLARATION CHECKLIST HEALTH DECLARATION CHECKLIST

NAME:___________________ DATE:__________ TIME:_______ NAME:___________________ DATE:__________ TIME:_______

GRADE:____ SECTION: ___________ AGE: ______ STUDENT ( ) GRADE:____ SECTION: ___________ AGE: ______ STUDENT ( )
CELL NUMBER:___________________ PARENT/GUARDIAN ( ) CELL NUMBER:___________________ PARENT/GUARDIAN ( )
ADDRESS: ________________________________ VISITOR ( ) ADDRESS: ________________________________ VISITOR ( )

MERON KA BANG NAG TRAVEL KA BA SA MGA MERON KA BANG NAG TRAVEL KA BA SA MGA
NARARAMDAMAN SA KASALUKUYAN? LUGAR NA MAY COVID? SAAN? NARARAMDAMAN SA KASALUKUYAN? LUGAR NA MAY COVID? SAAN?
Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES Pakilagyan ng tsek (/) kung meron PAKILAGAY ANG ADDRES

SIPON OO SIPON OO
UBO HINDI UBO HINDI
UBO/SIPON ADDRESS: UBO/SIPON ADDRESS:
UBO/HIRAP HUMINGA UBO/HIRAP HUMINGA
HIRAP HUMINGA HIRAP HUMINGA
LAGNAT/TEMPERATURE_____ LAGNAT/TEMPERATURE_____
WALA WALA