Tool
Para sa mga Magulang
Notice to Reporting Personnel
Visitor's Declaration Form
Teacher's Record
Logsheet
School Head's Summary
Description
For distribution to parents of learners who will report to school; may
be part of the parent's consent that they will sign in approving
learner's physical reporting to school
For display at the entrance gate and/or for distribution to reporting
personnel (may be signed at least once)
For visitors who will enter the school; to be accomplished by the visitor
and assessed properly by designated school staff prior to approval of
entry (there must be guidelines as to when visitors may be
accommodated and for what identified purposes)
For teachers to keep per class, each day, during health routine
inspection (teacher may be provided with step-by-step instruction on
how to facilitate the inspection using the tool)
For safekeeping at the Clinic c/o the Clinic Teacher/Nurse to record all
cases managed at the Clinic
The school head shall keep a summary of the health status of learners
and personnel, especially those who will manifest COVID-19 symptoms
for proper monitoring and identification of necessary next steps
 Symptoms Translation/Description
01 Fever Lagnat/ang body temperature ay 37.5 C o higit pa
02 Cough Ubo
03 General weakness Panghihina ng katawan
04 Fatigue/Tiredness Pagkapagod
05 Headache Pananakit ng ulo
06 Muscle/joint/body pains Pananakit ng katawan, kalamnan, kasu-kasuan
07 Sore throat Pananakit o pamamaga ng lalamunan
08 Colds/runny nose Sipon
09 Difficulty of breathing Pagkahapo o hirap sa paghinga
10 Loss of appetite Kawalan ng ganang kumain
11 Nausea Nasusuka
12 Vomiting Pagsusuka
13 Diarrhea Pagtatae
14 Loss of smell Pagkawala ng pang-amoy
15 Loss of taste Pagkawala ng panlasa
16 Rashes Mga butlig sa balat; pamumula ng balat (maaaring makati o hindi)
17 Others Mga sintomas o obserbasyon sa pangangatawan o pagkilos ng tao/bata na ka
g makati o hindi)
o pagkilos ng tao/bata na kailangan ng atensyong medikal
 Paalala sa mga Magulang/Guardian

Kung ang inyong anak po o ang sinuman sa inyong sambahayan ay kasalukuyang

nakararanas o nakaranas sa nakalipas na 14 na araw ng alinman sa mga sumusunod na
sintomas, mangyari pong huwag na munang papasukin ang bata sa eskwela (Lagyan ng / ).

___ Lagnat ___ Pananakit ng Katawan, Kalamnan

___ Ubo ___ Sipon
___ Panghihina ng Katawan ___ Nasusuka/Pagsusuka
___ Pagsakit ng Ulo ___ Hirap sa Paghinga
___ Pananakit ng Lalamunan ___ Pagkawala ng Pang-amoy/Panlasa
Huwag din po munang papasukin sa eskwelahan ang inyong anak kung siya o ang sinuman
sa inyong sambahayan ay nagpositibo sa COVID-19, naging close contact ng COVID-19 case,
o nadiagnose sa pneumonia.

Ipagbigay alam po agad ang sitwasyon sa kanilang guro na si G/Gng/Bb. _______________,

sa numero bilang ___________________, upang maisaayos ang alternative delivery mode
para sa kanilang pag-aaral habang sila ay nasa bahay.
Mangyari pong imonitor ang kondisyon ng inyong anak o kasama sa bahay, at iulat sa inyong
Barangay Health Emergency Response Team (BHERT), Barangay Health Station, o Rural
Health Unit, kung kinakailangan, upang sila ay mabigyan ng kaukulang lunas.

Ipinapabatid din po ng pamunuan ng ___________________________________ na

imomonitor po ng kanilang mga guro ang mga mag-aaral na pumapasok sa paaralan at
ipagbibigay-alam agad sa inyo at sa mga kinauukulan kung sila ay ma-obserbahan o maiulat
na nakakaranas ng alinman sa mga sintomas na nabanggit sa itaas.

Mangyari pong itago o idisplay sa inyong bahay ang paalalang ito upang magsilbing gabay
para sa pagdedesisyon sa araw-araw na pagpasok ng inyong anak sa paaralan.

I hereby certify that the information given is true, correct and complete. I understand that
failure to answer any question or any falsified response may have serious consequences. I
understand that my personal information is protected by RA 10173 or the Data Privacy Act of
2012 and that this form will be destroyed after 20 days from the date of accomplishment,
following the National Archives of the Philippines protocol.
I hereby certify that the information given is true, correct and complete. I understand that
failure to answer any question or any falsified response may have serious consequences. I
understand that my personal information is protected by RA 10173 or the Data Privacy Act of
2012 and that this form will be destroyed after 20 days from the date of accomplishment,
following the National Archives of the Philippines protocol.

Signature (Lagda): ____________________

 Notice to Reporting Personnel
By proceeding to report to school today, you guarantee the school management that neither
you nor any member of your household experiences any of the following symptoms (Put a
Check [ / ] ):
___ Fever ___ Muscle/Joint/Body Pains
___ Cough ___ Colds/Runny Nose
___ General Weakness ___ Nausea/Vomiting
___ Headache ___ Difficulty of Breathing
___ Sore Throat ___ Loss of Smell/Taste

You also confirm that neither you nor any member of your houshold is currently tagged as
COVID-19 positive or a close contact of a COVID-19 positive case, or has been diagnosed with
pneumonia.

If you experience any of the abovelisted symptoms while you are in school, kindly report
immediately to the School Clinic for appropriate assessment and/or referral as needed.
Health Declaration Form
Source: COMELEC (Note: Ask DOH of standard declaration form, and appropriate action per reported information [e.g., do not allow entry if they checked "yes" to any statement
ked "yes" to any statement?], if available.)
 CLASSROOM DAILY HEALTH MONITORING TOOL FOR COVID-19

Grade Level: V Section: LILY

Instruction: Write under each column date the code(s) of the symptom(s) observed in the learner during the routine inspection, during the conduct of the class, or as reported by the learner or their classmates.
Refer to the list of symptoms below and their respective codes:

Fv Fever F/T Fatigue/Tiredness ST Sore throat LoA Loss of appetite D Diarrhea R Rashes
C Cough HA Headache C/RN Colds/runny nose N Nausea LoS Loss of smell EN Essentially Normal
GW General weakness MJBP Muscle/joint/body pains DB Difficulty of breathing Vm Vomiting LoT Loss of taste A Absent
Others (Please specify)

Symptoms Observed/Reported
NAME
Monday Tuesday Wednesday Thursday Friday
TEMP. IN TEMP. OUT TEMP. IN TEMP. OUT TEMP. IN TEMP. OUT TEMP. IN TEMP. OUT TEMP. IN TEMP. OUT

Note: As soon as any of the listed symptoms is observed among any of the learners, the teacher is expected to send the learner to the School Clinic immediately for the proper management by the School Clinic
Teacher or health personnel.

Submitted by: Noted by:

CHERYL S. PUTIS PHOEBE D. PANGASIAN
Classroom Adviser Clinic Teacher
Date Time Name Age Sex Grade & Teacher Adviser Chief Complaint(s) Doctor's Order Treatment Administered By Remarks Follow-up Status
Admitted Section [Reason(s) for the clinic [To be initialed by the Medical [Indicate how the instructions of the doctor were [As needed; Date/Status]
visit/reported symptom(s)] Officer upon visit]/ Supported by followed, as well as other actions taken; e.g., ordered
the doctor's to return to classroom, what time; reported to BHERT,
Prescription/Instruction Slip specify contact number; informed the parent about
instructions, fetched by; etc.]

_ Administer treatment Paracetamol 5ml, given at

_ Contact the parents 10:30 am
_ Refer to health facility
_ Report to BHERT
 WEEKLY SUMMARY OF HEALTH STATUS OF PERSONNEL AND LEARNERS
Inclusive Dates: ________________
School

Name Category Grade Level/Section Date Reported Symptom(s) Action Taken

(Personnel/Learner) Observed/Reported (Referred to)
COVID-19 Status per Follow-Up
(Positive/Negative)
MAY GO HOME SLIP

Date:
Name
Age
Sex
Grade/Section
Teacher-Adviser

This certifies that the learner has been provided initial management at the clinic, with instructions from:
Name of Doctor:

The doctor has given instruction that the learner may go home/be fetched by his/her parent/guardian.

Signed:

Clinic Teacher/Nurse

This certifies that I have been provided important information/instructions by the clinic teacher/nurse:

Signed:

Name of fetcher:
Relation to the child:
Time fetched:

Present this May Go Home Slip and cut and leave the upper portion of the slip to the guard before leaving the school.

This lower portion may be brought home by the parent/fetcher.

REMINDERS TO THE PARENT

_ Please monitor the following:

_ Please consult with…

_ Your child has been reported to the BHERT ( __________________ ); please coordinate with them for the next steps
_ Please inform the school immediately if your child tests positive for COVID-19.
_ Medical certificate/clearance is required before the learner is allowed to return to face-to-face classes, subject to the ap

Other instructions:
ore leaving the school.

them for the next steps

ce classes, subject to the approval of the DepEd Medical Officer.

<Address>
<Name of Doctor>
<Position>
<Name of Doctor>
<Position>