Republic of the Philippines Republic of the Philippines
Department of Education Department of Education
Region X Region X
School Division of Misamis Occidental School Division of Misamis Occidental
UPPER BAUTISTA PRIMARY SCHOOL UPPER BAUTISTA PRIMARY SCHOOL
HEALTH CHECKLIST / DECLARATION FORM HEALTH CHECKLIST / DECLARATION FORM
Temperature: ______________ Temperature: ______________
Name: Age: Name: Age:
Address: Sex: Address: Sex:
REMINDERS: REMINDERS:
Observe social distancing at least 1 meter. Observe social distancing at least 1 meter.
Handwashing station/ alcohol dispenser in strategic location Handwashing station/ alcohol dispenser in strategic location
Accomplish questionnaire/ Health Checklist upon entering the premise Accomplish questionnaire/ Health Checklist upon entering the premise
Use personsal pens or use sanitizers before and after using provided pens. Use personsal pens or use sanitizers before and after using provided pens.
No mask, No Entry Policy No mask, No Entry Policy
Instructions: Check (/) if YES or NO for each item provided , if there YES NO Instructions: Check (/) if YES or NO for each item provided , if there YES NO
is any is any
Before coming to school today, did you experience flu-like Before coming to school today, did you experience flu-like
symptoms like: symptoms like:
a) Body Pain a) Body Pain
b) Headache b) Headache
c) Cough c) Cough
d) Sore Throat
e) Fever in past 14 days
d) Sore Throat
f) Close contact with Covid-19 patients e) Fever in past 14 days
g) Travel outside the Philippines f) Close contact with Covid-19 patients
h) Travel to Ozamis City g) Travel outside the Philippines
i) Travel to any area in the NCR or other h) Travel to Ozamis City
Regions where Covid-19 cases are confirmed.
i) Travel to any area in the NCR or other
If you have any of the following symptoms , you are not allowed to enter the school. Please
Regions where Covid-19 cases are confirmed.
be advise to go to your healthcare provider for consultation. If NONE , you can enter the
If you have any of the following symptoms , you are not allowed to enter the school. Please
school to proceed with your transaction.
be advise to go to your healthcare provider for consultation. If NONE , you can enter the
Declaration and Data Privacy Consent Form:
school to proceed with your transaction.
The information I have given is true, correct and complete. I understand that failure to answer
any question or giving false answer can be penalized in accordance with law.
Declaration and Data Privacy Consent Form:
I voluntarily and freely consent to the collection and sharing of the above personal information
The information I have given is true, correct and complete. I understand that failure to answer
only in relation to the HRep COVID - 19 internal protocols.
any question or giving false answer can be penalized in accordance with law.
I voluntarily and freely consent to the collection and sharing of the above personal information
Name and Signature Date
only in relation to the HRep COVID - 19 internal protocols.
Please be advised that the above information shall be used in relation to the HRep
COVID - 19 internal protocols in accordance with the Data Privacy Act. For any concerns, Name and Signature Date
you may contact [Link]@[Link]
Please be advised that the above information shall be used in relation to the HRep
COVID - 19 internal protocols in accordance with the Data Privacy Act. For any concerns,
you may contact [Link]@[Link]
