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Annex “C”

Post Examination Health Surveillance Form

Instructions: Please continue to follow social distancing and the wearing of face mask
even after the exam. You are required to send an email at car.examination@prc.gov.ph
fifteen (15) days after the last examination date. Please provide truthful information
relative to your health status by November 28, 2022.

Dear PRC,

Good day! I took the Nurses Licensure Examination last November 12 & 13, 2022. I would
like to inform you of my health status as of November 28, 2022.

Name: Dumangeng, Claire Gumidli


Testing Venue: Baguio City
Room No: 71
Seat No: 14

My health status is I (Please check(✓)all relevantitems)

_✔️_ have no symptom/s.

or
___ am with the following symptom/s:
___ fever
___ cough
___ easy fatigability
___ other signs/ symptoms or remarks: ___________

After completing the message, you will receive an acknowledgment and/or further
instructions from PRC.

Thank you for your cooperation and STAY SAFE.

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