Self-Monitoring Compliance Form

Indicate the compliance of your institution using the indicators below. Submit the form to the
City Disaster Risk Reduction Management Office at cdrrmoantipolocity1@gmail.com for
validation, subject to inspection by the Local Task Force against COVID-19.

Date: _______________________________________________________________________________
Name of Establishment: _______________________________________________________________
Owner: _____________________________________________________________________________
Location: ____________________________________________________________________________
Status of Business: With Permit Without Permit

Safety Requirements Compliant

Yes No
Establishments must be registered to SafePass or StaySafe.ph, or must
utilize a contact-tracing form/method (record book) and health
declaration form.
Entry and exit points must be established and directional signages must
be placed within the establishment. Entry protocols must be strictly
implemented (e.g. wearing of face masks, temperature scanning, QR
Code scanning) for learners, employees, teaching and non-teaching staff,
and visitors.
Visual alerts/ instructions on maintaining MPHS/ IEC materials for
COVID-19 risk mitigation measures must be displayed/posted in
common areas within the premises in all entrances and exits of the
institution and workshop (e.g. signage for “No Masks, No Entry”,
“Maintain 1 Meter Social Distancing,” respiratory hygiene, cough
etiquette, proper use of face masks, hand hygiene, and proper disposal of
used tissue).
Availability/utilization of no-touch digital thermometer/ thermal
scanner at the main entrance.
Presence of disinfection areas, hand washing facilities, availability of
sanitizers, disinfectant, and alcohol-based dispensers,
disinfection/sanitation footbath in buildings and room entrances.
Establishment of an Isolation Area for symptomatic or COVID-19
positive.
Adequate ventilation inside confined spaces and air-conditioned rooms
which ensures better airflow through natural ventilation or mechanical
ventilation methods as applicable.
Health personal protective equipment by all employees and
learners/scholars (e.g. face masks, face shield).
Learners, candidates, trainers, assessors, employees have complied with
the daily contact tracing/health survey requirement.
Re-configured workshops/training spaces to address the need for
physical/social distancing for the face-to-face training.
Seat configuration or floor lay-out plan in conduct of orientation/ TIP/
training/ assessment are prepared.
The physical distancing of 3 feet or 1 meter between learners, candidates
for assessment, trainers, assessors, and all other TVI/AC personnel are
being followed.
Physical Facilities Maintenance & Disinfection Plan indicating regular
disinfection and sanitation of all workstations, workshops, and
laboratories, rooms, buildings, tools, equipment, and facilities used
during training.
Establishment of Crisis Management Committee in Training Institution
and designation of safety officers.

*Adopted from Annex A, B, and C of TESDA Circular No. 096 s. 2021 issued 15 November 2021 entitled “Omnibus
Guidelines for TVET under the New Normal Arrangements.”