Republic of the Philippines

Department of Education
Region X
Division of Camiguin
District of Mambajao
TAGDO ELEMENTARY SCHOOL
Tagdo, Mambajao, Camiguin
SY. 2021-2022

STRATEGIES TO PREVENT COVID-19

Daily rapid health check in the classroom
GRADE I- B
SET A

March 2022 Week 1 Temperature/Hand Hygiene

Name of Learners MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Temp HH Temp HH Temp HH Temp HH Temp HH
1.Aliman, Jay Lourd L.
2.Cabutaje, Kyle John D.

3.Jamito, James Matthew L.

4.Labe, Nichad Adam B.
5. Ragas, Jayson T.
6.Sacote, Francis Jr., D.
7.Casanos, Ma. Kristel E.
8.Honculada, Anica Jane A
9.Honculada, Anica Mae A.
10.Quiblat, Precious C.
11.Quiblat, Princess C.
12.Uayan, Blessy Jane A.

Prepared:

JOY CELESTE L. SANCHEZ

Grade I- B Adviser
 Republic of the Philippines
Department of Education
Region X
Division of Camiguin
District of Mambajao
PANDAN ELEMENTARY SCHOOL
Pandan, Mambajao, Camiguin
SY. 2021-2022
STRATEGIES TO PREVENT COVID-19
Daily rapid health check in the classroom
GRADE V- ROSE
SET A
March 2022 Week 1 Temperature/Hand Hygiene
Name of Learners MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
Temp HH Temp HH Temp HH Temp HH Temp HH
1. Abueva, CJ G.
2. Arbuis, Luke Niño M.
3. Bodiongan, Radjah Rex
4. Ipanag, Russel Dave A.
5. Labis, John Paul S
6. Lagang, Rave L.
7. Libres, Nikko S.
8. Locloc, Basil M.
9. Oclarit, John A.
10. Polestico, John Paul G.
11.Sagrado, Kevin P.
12. Subrabas, Virnie
1. Agbu, Reanna Isabelle
2. Amparo, Imigrace M.
3. Ariata, Pauline Rose C.
4. Baculanta, Princess
5. Lantaca, Shaiwen M.
6. Magkilat, Alexandra
7. Malaque, Keith Ashley
8. Monton, Marianne
9.Ochavillo, Dyosa O.
10. Orlasan, Ellah Mae C.
11.Retor, Zairyl Grace S.
12. Salem, Kristine Jean A.
13. Suhayon, Catherine C.
14. Yatol, Angelica Joy G.

Prepared:
 MA. CHRISTINE N. OCLARIT
Grade V- Rose Adviser

Republic of the Philippines

Department of Education
Region X
Division of Camiguin
Mambajao II District
PANDAN ELEMENTARY SCHOOL
Pandan, Mambajao, Camiguin
SY. 2021-2022

SCHOOL NOTIFICATION FORM FOR COVID-19

IN CASE OF EMERGENCY, THE PANDAN ELEMENTARY SCHOOL SHOULD CONTACT

THE FOLLOWING:

NAME: ______________________________________________

ADDRESS: __________________________________________

CELLPHONE NUMBER: ____________________________________

OR

NAME: _______________________________________________

ADDRESS: __________________________________________

CELLPHONE NUMBER: ____________________________________

______________________________ ____________________________

PRINTED NAME SIGNATURE (date)

 Republic of the Philippines
Department of Education
Region X
Division of Camiguin
Mambajao II District
PANDAN ELEMENTARY SCHOOL
Pandan, Mambajao, Camiguin
SY. 2021-2022

REFERRAL FORM

COVID-19 Referral Form

Patient Demographic Information

Patient Name:

Gender:

Date of Birth:

Phone:

Address:

City/Town:

Province:

Assessment Details

Must present with ONE of the

Must meet ONE of the following criteria:
following:

☐ Contact with confirmed or probable case

☐ Fever / chills
within the past 14 days

☐ Close contact with a person with acute

☐ New onset of (or exacerbation of
respiratory illness who traveled outside of
chronic) cough
Camiguin in the last 14 days

☐ Had laboratory exposure to biological

material (e.g., primary clinical specimens,
virus culture isolates) known to contain
COVID-19.
Republic of the Philippines
Department of Education
 Region X
Division of Camiguin
Mambajao II District
PANDAN ELEMENTARY SCHOOL
Pandan, Mambajao, Camiguin
SY. 2021-2022

Travel Details

Travel Details
Travel Destination
Date left the Province

Date Returned to Province

Date of Symptom onset

If not travel related, was patient in

contact with confirmed or probable
case of COVID19

Refer to following
Assessment/Screening Centre

Republic of the Philippines

Department of Education
Region X
Division of Camiguin
Mambajao II District
PANDAN ELEMENTARY SCHOOL
Pandan, Mambajao, Camiguin
SY. 2021-2022

HEALTH DECLARATION FORM FOR COVID-19

Name: _________________________________________ Address: ______________________________

Contact Number: _______________________

Please mark with  on “YES/”NO” column.

NO CONDITIONS YES NO
 I have a cold/cough/fever (> 37.5ºC)/sore throat/shortness of
1.
breath or history of symptoms that are suspected as COVID-19

Within the last 14 days I have a history of traveling to

2.
countries/regions/cities that have been infected with COVID-19

Within the last 14 days there is a family member/person under

3. the same roof with me who has a history of traveling to
countries/regions that have been infected with COVID-19

I am included in the COVID-19 Supervisory List for having

4. COVID-19 symptoms, or COVID-19 Patient under Surveillance, or
suspected or proven positive patient for COVID-19

Within the last 14 days I have interacted or conducted any

5. physical contact with people who have a status of ODP, or PDP,
or suspected or proven positive for COVID-19