DepEd – DIVISION OF QUEZON

Sitio Fori, Brgy. Talipan, Pagbilao, Quezon QUALITY

ASSURED

Trunkline # (042) 784-0366, (042) 784-0164, (042) 784-0391, (042) 784-0321

COMPANY
ISO 9001

www.depedquezon.com.ph Registration Number:

“Creating Possibilities, Inspiring Innovations” QAC/R63/0216

HEALTH FACILITY MONITORING CHECKLIST

School: Danlagan Elem. School ID No: 108732 Teacher In Charge: Ma. Cristina C. Magpantay
School Address: Danlagan Reserva Guinayangan Quezon Contact Number: 09307173077
Total School Population: Teacher/ Staff: 7 Pupils:131

Comments/Suggestions: _________________________________________________________________
_________________________________________________________________
Issues and Concerns: ____________________________________________________________________
____________________________________________________________________

EXISTING
RECOMMENDED FOR CONSTRUCTION OF HEALTH FACILITY
HEALTH
(please check the box below if health facility is/are applicable for construction)
FACILITY
Required Lot With Actual Lot
FOR
Area Buildable Area Remarks
REPAIR
FACILITY (Meter) Space In meters (M)
lengt widt widt
YES NO length YES NO
h h h
SCHOOL CLINIC 13 13.5 / 10 10.5 /
SUBMERSIBLE WATER PUMP 12 7 / 10 7 /
RAIN WATER COLLECTOR 10 5 / 10 5 /
TOILET 10 6 / 10 6 /
10.5 10 /
HANDWASHING 10 /
10.5

Comments/Suggestions: ________________________________________________________________
________________________________________________________________
Issues and Concerns: ____________________________________________________________________
____________________________________________________________________

DEPEDQUEZON-TM-SDS-04-025-002
Email address: quezon@deped.gov.ph
Comments: Txt HELEN – 09178902327 (Smart/Sun/TalknTxt) 2327 (Globe and TM)

This form is a property of SCHOOLS DIVISION OFFICE - QUEZON PROVINCE. Therefore, unauthorized use is strictly prohibited unless otherwise
permitted by the Schools Division Superintendent.
 DepEd – DIVISION OF QUEZON
Sitio Fori, Brgy. Talipan, Pagbilao, Quezon QUALITY
ASSURED

Trunkline # (042) 784-0366, (042) 784-0164, (042) 784-0391, (042) 784-0321

COMPANY
ISO 9001

www.depedquezon.com.ph Registration Number:

“Creating Possibilities, Inspiring Innovations” QAC/R63/0216
ATTACHMENT:
Pictures:
HW Facility/Water source (If Pump/Deep well)/Rainwater collector (If present)/ Gender Segregated
Toilet
Possible lot where construction is possible

Evaluated by: Conforme:

GENESIS E. OLARTE MA. CRISTINA C. MAGPANTAY

(Signature over printed Name) (Signature over printed Name)
Nurse II Officer In Charge

_______________________________
Date

KATHERINE M. CLEOPE
(Signature over printed Name)
DRRM Coordinator

_______________________________
Date

DEPEDQUEZON-TM-SDS-04-025-002
Email address: quezon@deped.gov.ph
Comments: Txt HELEN – 09178902327 (Smart/Sun/TalknTxt) 2327 (Globe and TM)

This form is a property of SCHOOLS DIVISION OFFICE - QUEZON PROVINCE. Therefore, unauthorized use is strictly prohibited unless otherwise
permitted by the Schools Division Superintendent.
 DepEd – DIVISION OF QUEZON
Sitio Fori, Brgy. Talipan, Pagbilao, Quezon QUALITY
ASSURED

Trunkline # (042) 784-0366, (042) 784-0164, (042) 784-0391, (042) 784-0321

COMPANY
ISO 9001

www.depedquezon.com.ph Registration Number:

“Creating Possibilities, Inspiring Innovations” QAC/R63/0216
________________________________
(Signature over printed Name)
Dentist II
_______________________________
Date

DANLAGAN ELEMENTARY SCHOOL

Pictures:
HW Facility/Water source (If Pump/Deep well)/Rainwater collector (If present)/ Gender Segregated
Toilet
Possible lot where construction is possible

DEPEDQUEZON-TM-SDS-04-025-002
Email address: quezon@deped.gov.ph
Comments: Txt HELEN – 09178902327 (Smart/Sun/TalknTxt) 2327 (Globe and TM)

This form is a property of SCHOOLS DIVISION OFFICE - QUEZON PROVINCE. Therefore, unauthorized use is strictly prohibited unless otherwise
permitted by the Schools Division Superintendent.
 DepEd – DIVISION OF QUEZON
Sitio Fori, Brgy. Talipan, Pagbilao, Quezon QUALITY
ASSURED

Trunkline # (042) 784-0366, (042) 784-0164, (042) 784-0391, (042) 784-0321

COMPANY
ISO 9001

www.depedquezon.com.ph Registration Number:

“Creating Possibilities, Inspiring Innovations” QAC/R63/0216

DANLAGAN ELEMENTARY SCHOOL

Pictures:
HW Facility/Water source (If Pump/Deep well)/Rainwater collector (If present)/ Gender Segregated
Toilet
Possible lot where construction is possible

DEPEDQUEZON-TM-SDS-04-025-002
Email address: quezon@deped.gov.ph
Comments: Txt HELEN – 09178902327 (Smart/Sun/TalknTxt) 2327 (Globe and TM)

This form is a property of SCHOOLS DIVISION OFFICE - QUEZON PROVINCE. Therefore, unauthorized use is strictly prohibited unless otherwise
permitted by the Schools Division Superintendent.