REPUBLIC OF THE PHILIPPINES REGION X – NORTHERN MINDANAO

DEPARTMENT OF EDUCATION DIVISION OF OZAMIZ CITY

REGION X – NORTHERN MINDANAO TABID NATIONAL HIGH SCHOOL
DIVISION OF OZAMIZ CITY TABID, OZAMIZ CITY
TABID NATIONAL HIGH SCHOOL
TABID, OZAMIZ CITY COVID – 19 DAILY SCREENING QUESTIONNAIRE

COVID – 19 DAILY SCREENING QUESTIONNAIRE NAME OF LEARNER: _____________________GRADE & SECTION: ___________
ADDRESS: __________________TEMPERATURE: _______DATE: ____________
NAME OF LEARNER: _____________________GRADE & SECTION: ___________
ADDRESS: __________________TEMPERATURE: _______DATE: ____________ In the last week, have you had any of the following signs or symptoms?

In the last week, have you had any of the following signs or symptoms? Screening Questions YES NO
13. Fever or Chills
Screening Questions YES NO 14. New Cough(excludes asthma, allergies) I
1. Fever or Chills 15. Shortness of Breath or difficulty breathing attest
2. New Cough(excludes asthma, allergies) I attest that
16. Loss of taste or smell
3. Shortness of Breath or difficulty breathing that the
17. Sore throat
the
4. Loss of taste or smell 18. Unexplained fatigue
above
5. Sore throat
6. Unexplained fatigue 19. Muscle or body ache (unrelated to exercise
20. New (unusual) Headache
7. Muscle or body ache (unrelated to exercise 21. Nasal Congestion or runny nose
8. New (unusual) Headache 22. Nausea or vomiting
9. Nasal Congestion or runny nose 23. Diarrhea
10. Nausea or vomiting 24. Travelled outside Ozamiz City
11. Diarrhea above information is truthful and accurate. I also pledge
12. Travelled outside Ozamiz City to follow all policies and procedures to minimize the risk of COVID-19 transmission,
information is truthful and accurate. I also pledge including wearing a mask at all times.
to follow all policies and procedures to minimize the risk of COVID-19 transmission,
including wearing a mask at all times. SIGNATURE: ______________________ CONTACT NUMBER: _________________

SIGNATURE: ______________________ CONTACT NUMBER: _________________

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION