COVID19 Workplace School Screening Form

Republic of the Philippines
Department of Education
CARAGA - REGION XIII
Schools Division of Agusan Del Norte
District/ Office: LAS NIEVES II
School: E.G. MONTILLA ELEMENTARY SCHOOL
OFFICE OF THE SGOD: HEALTH AND NUTRITION SECTION
*COVID-19 SAFE WORKPLACE/SCHOOL

PUPILS’ ATTENDANCE
KINDERGARTEN – ROSE (Class A)

HISTOR
Y OF
DATE **RESPIRATORY TRAVEL
AND BODY SYMPTOMS? TO PURPOSE OF VISIT/ CONTACT TIME-
EMPLOYEE / LEARNER SIGNATURE
TIME- TEMP (Y/N; COVID- INTERVENTIONS DONE NUMBER OUT
IN If Y, pls. specify) 19
AREAS
(Y/N)
1. AROSA, RONILO JR.
2. BAGUIDAN, KENNITH D.
3. BERMOY, AJ CYMON G.
4. BONGGANAY, JOHN KENNETH A.
5. BUSCAGAN, STEVEN JAMES G.
6. CABALLAR, LEV KENT NEO

GENERAL N.
1. ALVARADO, GABRIELLA AISHAH S.
2. ALVERO, JULIA GRACE M.
3. AMAD, SHEIRA MAE O.
4. BATIS, KIM DIANA O.
5. CORDERO, CHRISTY O.
6. CUAREZ, CHENCY A.
7. GALINDEZ, LEISA JANE R.
*Fill-up for employees whose initial temperature reading is 37.5C and above.
**Fever/ temp above 37.5C, coughing, shortness of breath or difficulty breathing; other early symptoms to watch for are chills, body aches, sore throat, headache, diarrhea,
nausea/vomiting, and runny nose, loss of appetite/ smell)
Prepared by:
ARLYN M. ACLON Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

KINDERGARTEN – ROSE (Class B)

HISTOR
Y OF
AREAS
(Y/N)
1. CRUDA, JAIRUS JEFF B.
2. CUADRADO, RJ B.
3. EBILLO, PRINCE JIMS NAZARENE S.
4. FERRER, MARQUEL R.
5. GABATO, KHENT STEPHEN JAY
6. LARGO, IAN REY B.

7. MACEDA, ACE GABRIEL B.
1. JOVELLAR, DENLEAH APRILYN M.
2. JOVILLAR, LADY JEAN T.
3. KINALANGAN, MITCHELYN V.
4. LUMBAY, PRINCESS N.
5. MATILOS, TREZIA MAE E.
6. MENDOZA, JACKIE B.
*Fill-up for employees whose initial temperature reading is 37.5C and above.
**Fever/ temp above 37.5C, coughing, shortness of breath or difficulty breathing; other early symptoms to watch for are chills, body aches, sore throat, headache, diarrhea,
nausea/vomiting, and runny nose, loss of appetite/ smell)
Prepared by:
ARLYN M. ACLON Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

KINDERGARTEN – DAISY (Class A)

HISTORY
OF
AREAS
(Y/N)
1. MANIMBO, ARKEM T.
2. MATILOS, JOEL A.
3. MENDOZA, RJ ANDRICA
4. MIAO, JAMES KYLE R.
5. MONTES, GABRIEL JR. G.
6. OBANG, CARLOS MIGUEL A.

7. QUILARIO, JESREL D.
1. MENDEZ, JACKIE B.
2. MENDOZA, LHORIE JEAN
3. MONTILLANO, GLORIOUS T.
4. PAJAR, KEANNA MARIE O.
5. PRECIOSO, ALONNA M.
6. REDOBLE, CATALINA M.
Prepared by:
JENALEY J. OCIO Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

KINDERGARTEN – DAISY (Class B)

HISTORY
OF
AREAS
(Y/N)
1. SAYA-ANG, JAMES YVAN L.
2. SON, JOHN CEDRICK B.
3. SUTELLEZA, JAKE C.
1. REDOBLE. KIM A.
2. REDOBLE, SUSHANA ANDRIA L.

3. RETORTA, SHELLA JIE J.
4. RUAYANA, AMARIS SOPHIA B.
5. SABANDAL, MA. ALEXANDRA A.
6. SOTELLIZA, JANA MICHELLE C.
7. TIMTIM, ARIAN E.
8. TORRES, CHARMAINE SHIMIE Q.
Prepared by:
JENALEY J. OCIO Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE I - SQUASH (Class A)

HISTORY
DATE *RESPIRATORY
OF TRAVEL
AND BODY SYMPTOMS? PURPOSE OF VISIT/ CONTACT TIME-
EMPLOYEE / LEARNER TO COVID- SIGNATURE
TIME- TEMP (Y/N; INTERVENTIONS DONE NUMBER OUT
19 AREAS
IN If Y, pls. specify)
(Y/N)
1. DEIPARINE, RANIER M.
2. KIAWAN, JOHN
3. MATILOS, JOEM L.
4. NUYA NEIL T.
5. PEDRING, YOOHAN C.
6. QUILARIO, ALEXANDER G.
7. RETORTA, ESTRELLO JR. C.

1. ALVERO, ALTHEA M.
2. COMMENDADOR, RAQUEL D.
3. DELA RITA, GIELROSE D.
4. GABATO, MARY JOY
5. GENECIRAN, HASHANA M.
Prepared by:
JUSTINA M. BUTCON Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE I - SQUASH (Class B)

HISTORY
DATE *RESPIRATORY
OF TRAVEL
19 AREAS
(Y/N)
1. ROSAL, JONECRIS G.
2. SAGARBARRIA, ALLEN FRANCIS

H.
3. SON, JAMES JAVIER B.
4. SOTELLIZA, MICHAEL JR. C.
5. SUMALINOG, ANDRO A.
6. SUMALINOG, LAWRENCE R.
7. TIMTIM, AR JOHN E.
1. MALAQUE, FATIMA C.
2. OLAGUER, PRECIOUS AVIONA L.
3. REDOBLE, ALTHEA AVRIL
4. SOTELLIZA, IMGIE V.
Prepared by:
JUSTINA M. BUTCON Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE I - CARROT (Class A)

HISTORY
DATE *RESPIRATORY
OF TRAVEL
19 AREAS
(Y/N)
1. ABANIL, ANDRIE C.
2. ALTRECHA, KUERTON M.
3. CARILLERO, JOHN GABRIEL V.
4. DAMIAN, JONARD JR. E.
5. EBORDA, KIM JAY S.
6. GABATO, NATHANIEL
7. GABOTERO, MARK ANTHONY D.

1. ACHACOSO, LEN ANTOINETTE A.
2. CABARON, RESHALYN R.
3. DELICANO, AIRA JANE O.
4. LARGO, ANGELIE NICOLE A.
5. NEPOMUCENO, JOHNELA
FRANCHESKA A.
Prepared by:
LUISA L. ECO Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE I - CARROT (Class B)

HISTORY
DATE *RESPIRATORY
OF TRAVEL
19 AREAS
(Y/N)
1. GABOTERO, NORVAN O.
2. GODELUSAO, CRISTIAN N.
3. GUERRA, ATHAN B.
4. LABISTO, KJ D.
5. LARGO, AJ V.
6. MATILOS, NELMAR P.
1. PONIO, AIRA O.
2. REDOBLE, ANDREA P.
3. SONSONA, MARY GRACE S.
4. SOTELLIZA, ASHLEA R.
5. MENCIAS, HANNAH
Prepared by:
LUISA L. ECO Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE II - POLITE (Class A)
HISTORY
OF
AREAS
(Y/N)
1. MATILOS, KYLE C.
2. MEDALLO, NIKKO JAMES IVAN
3. MONTES, JM G.
4. PAJAR, KENT JOMARIE O.
5. REDOBLE, DONALD M.
6. RUAYANA, ELNATHAN AZARIAH B.
7. SAURO, JM S.
1. GOREZ, MARISSA S.
2. MEDALLO, NOVA CRYSTAL IVORY
3. OBANG, STEFHANIE A.
4. QUILARIO, JOMELA D.
5. GOREZ, MARISSA S.
Prepared by:
HALWEENA B. CRUDA Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE II - POLITE (Class B)
HISTORY
OF
AREAS
(Y/N)
1. ABAO, GAIL HARVEY
2. BAGUIDAN, WILFRED A.
3. BALURAN, KENTJOSH M.
4. BANDOJO, JAYPEE P.
5. BERMOY, AJ CYRUS G.
6. BUDOMO, BJ B.
7. ESCLAMADO, IVAN JAY M.

8. GABURAN, ORELY M.
1. BANDOJO, JANNELLE KIM T.
2. CABARON, NIKKI GRACE K.
3. DOUGAN, MARYJANE Q.
4. GABANE, KENDRA M.
Prepared by:
HALWEENA B. CRUDA Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE II - LOVE (Class A)
HISTORY
OF
AREAS
(Y/N)
1. ALVAREZ, FRANCIS T.
2. CORDERO, SAMLY O.
3. DAMIAN, DARWIN E.
4. GINANDOY, KIM FRANCIS B.
5. GOREZ, ARNEL D.
6. MATILOS, JAPOY A.
7. MATILOS, JOHN LLOYD I.

1. CUADRADO, MAICA B.
2. GOREZ, ANNAH D.
3. MATILOS, JILLIAN I.
4. NABO, JERYZA P.
5. RAMA, KYLIE NOVA C.
Prepared by:
NOEMI S. CAMACHO Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE II - LOVE (Class B)
HISTORY
OF
AREAS
(Y/N)
1. MENDOZA, RALPH HERV
2. MONDRAGON, CHARLZ LORENZ
3. OLAMIT, FILMAR O.
4. PAESTE, JHON CRUISE B.
5. PALERO, MIKAEL J.
6. SILLOSO, DEMCEL R.
7. TARE, CHRISTIAN C.
1. REDOBLE, CRISTINE JOY R.
2. REDOBLE, CRISTY MARIEL P.
3. SILLOSO, AUGUST JOY R.
4. SOTELLIZA, JANNE CHLOE C.
5. VILLANUEVA, CLYDEL A.
Prepared by:
NOEMI S. CAMACHO Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE III - GUAVA (Class A)
HISTORY
OF
AREAS
(Y/N)
1. MALAQUE, JOHN C.
2. MATILOS, DJ L.
3. MATILOS, NEO JHUN REX P.
4. MENDEZ, JASON B.
5. MENDEZ, RALPH P.
1. CABALLAR, DEVUN N.
1. FERRER, CYRA R.
2. GODELUSAO, SHEENA N.
3. GOREZ, CHARICE S.
4. MATILOS, HANNA C
5. MONTES, GLAIZA MAE G.
Prepared by:
ARCHIE S. BERMOY Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE III - GUAVA (Class B)
HISTORY
OF
AREAS
(Y/N)
1. MENDOZA, BLAIR P.
2. OLAMIT, FILJIE O.
3. REDOBLE, DINDO JR. M.
4. REDOBLE, JENITO JR. N.
5. REDOBLE, KENT A.
1. NUYA, PRECIOUS LHORAINE A.

2. REDOBLE, JUDY-ANN A.
3. RETORTA, DARLENE B.
4. SABANDAL, JELYN G.
4. SABANDAL, JENEVA
5. SUTELLEZA, RYZA MAE C.
Prepared by:
ARCHIE S. BERMOY Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE III - MANGO (Class A)
HISTORY
OF
AREAS
(Y/N)
1. ALBERCA, KHEYO C.
2. ALVAREZ, KG O.
3. CABALLAR, RAM LEE S.
4. DABALOS, CHRISTIAN C.
5. DAYA, JHONE CRISTIAN
6. DIONALDO, B-JAMES O.
1. ACOG, CRECEL P.
2. AUTOR, WELLA AVRILLINE J.
3. BALURAN, ABEGUIL M.
4. BANAYAWON, JESSA NECLE B.
5. BELTRAN, MIKHAELA R.
6. BUSLON, SHEALYHXIE N.
Prepared by:
JOECYLINE G. BERMOY Noted:

Class Adviser
JUNIEL S. CABAG
School Principal

GRADE III – MANGO (Class B)
HISTORY
OF
AREAS
(Y/N)
1. EMBILE, MARCO S.
2. GARCIA, GIAN A.
3. GARCIA, NOBLER
4. LARGO, FRANZ TIMOTY OLY A.
5. LARGO, STEVEN B.
1. CAGAYAN, BRIANA C.
2. CAÑETE, CRISMEL G.
3. CHUA, ALIAH CANE V.
4. COMENDADOR, TRIXIE D.
5. DELLIRA, EMMA ROSE L.
6. ESCLAMADO, IVY JOY M.
Prepared by:
JOECYLINE G. BERMOY Noted:

Class Adviser
JUNIEL S. CABAG
School Principal
District/ Office:
School:
*SCHOOL CONTACT TRACING FORM

DATE NAME OF LEARNER / CONTACT NO. ADDRESS VAX STATUS LAST DAY OF NO. OF PERSONS S/SX FELT
PERSONNEL REPORTING IN CONTACT WITH (Y/N)
TO SCHOOL

COVID19 Workplace School Screening Form

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Republic of the Philippines

*COVID-19 SAFE WORKPLACE/SCHOOL

KINDERGARTEN – ROSE (Class A)

4. BONGGANAY, JOHN KENNETH A.

5. BUSCAGAN, STEVEN JAMES G.

6. CABALLAR, LEV KENT NEO

2. ALVERO, JULIA GRACE M.

3. AMAD, SHEIRA MAE O.

4. BATIS, KIM DIANA O.

7. GALINDEZ, LEISA JANE R.

ARLYN M. ACLON Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

KINDERGARTEN – ROSE (Class B)

3. EBILLO, PRINCE JIMS NAZARENE S.

5. GABATO, KHENT STEPHEN JAY

6. LARGO, IAN REY B.

1. JOVELLAR, DENLEAH APRILYN M.

2. JOVILLAR, LADY JEAN T.

5. MATILOS, TREZIA MAE E.

ARLYN M. ACLON Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

KINDERGARTEN – DAISY (Class A)

4. MIAO, JAMES KYLE R.

5. MONTES, GABRIEL JR. G.

6. OBANG, CARLOS MIGUEL A.

2. MENDOZA, LHORIE JEAN

4. PAJAR, KEANNA MARIE O.

JENALEY J. OCIO Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

KINDERGARTEN – DAISY (Class B)

2. SON, JOHN CEDRICK B.

2. REDOBLE, SUSHANA ANDRIA L.

4. RUAYANA, AMARIS SOPHIA B.

5. SABANDAL, MA. ALEXANDRA A.

6. SOTELLIZA, JANA MICHELLE C.

8. TORRES, CHARMAINE SHIMIE Q.

JENALEY J. OCIO Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

GRADE I - SQUASH (Class A)

7. RETORTA, ESTRELLO JR. C.

3. DELA RITA, GIELROSE D.

4. GABATO, MARY JOY

JUSTINA M. BUTCON Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

GRADE I - SQUASH (Class B)

2. SAGARBARRIA, ALLEN FRANCIS

4. SOTELLIZA, MICHAEL JR. C.

2. OLAGUER, PRECIOUS AVIONA L.

3. REDOBLE, ALTHEA AVRIL

JUSTINA M. BUTCON Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

GRADE I - CARROT (Class A)

3. CARILLERO, JOHN GABRIEL V.

4. DAMIAN, JONARD JR. E.

5. EBORDA, KIM JAY S.

7. GABOTERO, MARK ANTHONY D.

3. DELICANO, AIRA JANE O.

4. LARGO, ANGELIE NICOLE A.

LUISA L. ECO Noted:

*COVID-19 SAFE WORKPLACE/SCHOOL

GRADE I - CARROT (Class B)

3. SONSONA, MARY GRACE S.