Republic of the Philippines

Name Age Sex Nationality Contact Number

Address # of persons in the Other health Hypertension Others: Please specify

household conditions: Diabetes ______________________
Please check Asthma
History of travel to other Date returned to History of travel within Date returned to specific
countries? Philippines: the Philippines province:
Yes No Yes No
If yes, Please specify: If yes, Please specify:

History of exposure to a Date of last Casual Contact (Low-risk exposure)

confirmed Covid-19 exposure to  A person who was in a closed environment with COVID-19 case for less than 15 minor at
patient: confirmed a distance of more than 2 meters.
Covid-19 patients:  A person having face-to-face contact with a COVID-19 with less than15 min and a
distance of less than 2 meters.
______________  Traveling together with COVI-19 case in any kind of conveyance.
Nature of contact: Close Contact (High-risk exposure)
Yes  A person living in the same household as a COVID-19 case.
No Casual  A person having had direct physical contact with a a COVID-19 case (e.g. shaking hands).
Close  A person who was in a close environment (e.g. classroom, meeting room, hospital waiting
room, etc.).
 A contact in an aircraft sitting within two seats (in any direction) of the COVID-19 case,
travel companions or persons providing care, and crew members serving in the section of
the aircraft.

Department of Education
Region VIII
DIVISION OF SAMAR
Catbalogan

INDIVIDUAL CHECKLIST FOR PERSON UNDER MONITORING (PUM)

(For the use of School Health Personnel only)

Symptoms Diary: Please check accordingly

SYMPTOMS
No Fever equal
Day Shortness of Others
symptoms to or more Sore Throat Cough Runny Nose symptoms
Date –pls Breath
specify if than 38’C –pls
specify
none
Yes No Yes No Yes No Yes No Yes No
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Note:
a. Any household contact with clinical symptoms within 14 days of last exposure contact with the primary case
should be considered a symptomatic and so a possible suspect.
b. If the patient develop any of the symptoms listed during the observation period, please inform any of the contacts
below.
1. Dr. Angelica C. Rodriguez (Medical Officer) 4. RHU personnel
2. Barangay Captain 5. LGU
3. BHERT (Brgy. Health Emergency Response Team) 6. MDRRM

E-KULTURA: Edukasyon, Kultura ngan Turismo para han pag-uswag han Samar
Arteche Blvd., Brgy. 7, Catbalogan City, Samar, 6700, Philippines
(055) 251-2595 | depedsamarhrdd@gmail.com