Annex C

Post Examination Health Surveillance Form

Instructions: Please continue to follow social distancing and the wearing of face mask even
after the exam. You are required to send an email to the official email address of the
Regional Office where you took your licensure examination 15 days after the last
examination date. Please provide truthful information relative to your health status.
FOR PRC DAVAO:
Please send the accomplished this Annex C to: lethealthsurvey.prcdavao@gmail.com
ON 11 OCTOBER 2021

Dear PRC,

Good day! I took the PROFESSIONAL TEACHERS licensure examination last

(Profession)

26 September 2021 . I would like to inform you of my health status as of

(Date/s of Examination)

11 October 2021 :
(Date)

Name: Merasol L. Rebalde

Testing Venue: DAVAO CITY

Room No: 25

Seat No: 6

My health status is I (Please check all relevant items)

⁄ have no symptom/s.
am with the following symptom/s:
fever
cough
easy fatigability
other signs/ symptoms or remarks:

After completing the message, you will receive an acknowledgment and/or further instructions
from PRC.