Republic of the Philippines

Department of Education
Region VII, Central Visayas
Division of Cebu Province
District of Compostela
TAG-UBI INTEGRATED SCHOOL
Tag-ube, Compostela, Cebu

Health
DATE: ______________________________________
GRADE: 5 - AT(SET A) Declaration Are you experiencing: Have you stayed
Have you had any
contact with
Have you
Have you
travelled to any

Form
in the same close travelled outside
anyone with fever, area in NCR aside
environment of a of the Philippines
Fever for the cough, colds, and from your home?
TEMPERATURE Sore throat Body pains Headache confirmed in the last 14
past few days sore throat in the
NAME OF PUPILS COVID19 case?
past 2 weeks?
days?

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

1. ALGUNO, IAN CHARLES

2. BATICAN, ADRIAN

3. BATICAN, XIAN EARL

4. CAPOTE, JAMES SANDREI

5. COLA, GRUFF

6. COLA, JHANSEL CLENT

7. GOMEZ, RENIEL

8. GUILLEN, EDIE BOY

9. MATUGAS, MARVIN

10. MATUGAS, YUJI AERON

11. MONTERDE, CHRISTIAN ANGELO

12. NAQUINES, JANZEL EUMAN

13. NAQUINES, JHAMES

14. OLIVERIO, NHYJEL

15. OLIVERIO, RICKS ANDRIE

16. PENAS, JELMAR KIETH

17. ROSAL, HANS DERRICK

18. SAGAYSAY, SEAN PAUL

19. SARONA, KYLE JOSEPH

20. TORADO, JUNREL

21. ALGUNO, KHEMBERLY

22. ARANETA, JADE

23. CAPOTE, REIGNNAH

24. CODINO, JENECA

25. COLA, HELLORIE

26. LANZA, MICHAELA

27. LAURON, MARY ANGELA

28. LEYSON, LOVELY JOY

29. LIBRADO, KIMBERLY

30. NAQUINES, JANINE

31. OLIVERIO, PEACH ELIAJAH

32. QUIMOD, NICOLE JANE

33. RICA, ARRIANA

34. ROBLE, NANCY GRACE

35. SARONA, BLIZ ASHLY KEESHA

36. VILLA, SAMANTHA KAYE

Prepared by

AIRENE M. TAYO
Class Adviser

GRADE: 1 – AFR (SET A) TEMPERATUR Are you experiencing: Have you stayed Have you had any Have you
 contact with travelled
in the same
anyone with outside of the
close
Fever for the fever, cough,
Sore throat Body pains Headache environment of Philippines in
NAME OF PUPILS E past few days a confirmed
colds, and sore
throat in the past 2 the last 14
COVID19 case? days?
weeks?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
14. PEPITO, PRINCESS SHANE

15. SABAS, YASSY GHALE

16. TALISIC, CLEAR ANN

17. TUNDAG, MARY FAITH

Prepared by

JOYME T. BAARDE

Relieving Teacher
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Division of Cebu Province
District of Compostela
MULAO ELEMENTARY SCHOOL
Mulao, Compostela, Cebu

Health
DATE: MARCH 25, 2022
GRADE: 1 – AFR (SET B)
Declaration Are you experiencing: Have you stayed
Have you had any Have you
contact with
Form Fever for
in the same
close
environment of
anyone with
fever, cough,
travelled
outside of the
TEMPERATURE Sore throat Body pains Headache the past colds, and sore Philippines in
a confirmed
NAME OF PUPILS few days COVID19 case?
throat in the past the last 14
2 weeks? days?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
1.AM-IS, GABRIEL

2. ARENAS, ARBERT

3. BEDOLIDO, JAMES ROEL

4. BUGHAO, NETHAN

5. GALABIN, JOHN KRIST

6. HERAMIL, JOHN AXEL

7. MADRONERO, KENT HARRY

8. TALISIC, LEE

9. ENCABO, KATE DANIELLE

10. ESCOTO, KYARA

11. MANSUETO, THERESE JEAN

Prepared by
 AIRENE M.
TAYO
Have you had any Have you
GRADE: 1 – AFR (SET B) Are you experiencing: Have you stayed
contact with
in the same travelled
anyone with
Fever for close outside of the
fever, cough,
environment of Philippines in
TEMPERATURE Sore throat Body pains Headache the past a confirmed
colds, and sore
NAME OF PUPILS few days COVID19 case?
throat in the past the last 14
2 weeks? days?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
14. TAGALO, AZYL XAVIEL

15. TANJAY, LOUISE

16. TAROJA, LOVELY SHANE

Prepared by

JOYME T. BAARDE

Relieving Teacher