Annex “C”

Post Examination Health Surveillance Form

Please continue to follow social distancing and the wearing of face mask
exam. You are required to sendCPA an email at the official email address of the
ce where you take your licensure examination 15 days after the last
ate. Please provide truthful information relative to your health status.

ok the licensure examination last .

(profession) (date)

inform you of my health status as of .

(date)

October 10, 11 & 12, 2021.

____________________________________
e:___________________________________
_____
_____

us is: (Please check () all relevant items)

ymptom/s.
he following symptom/s:
ver
ugh
sy fatigability
her signs/ symptoms or remarks: ___________

ing the message, you will receive an acknowledgment and/or further

om PRC.