PULANG YUTA ELEMENTARY SCHOOL

S.Y. 2021-2022

HEALTH
DECLARATION FORM
FOR PUPILS
 HELP LINES AND
EMERGENCY NUMBERS
MDRRMMO
0915-235-5301

CAIBIRAN RHU
0917-110-3379

POLICE STATION
0938-984-9929

FIRE STATION
0905-839-8501

COVID HOTLINE
GLOBE 09214418621
SMART 09682169123

Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION VIII-Eastern Visayas
 Division of Biliran
Caibiran II
PULANG YUTA ELEMENTARY SCHOOL

CLASS PROGRAM
GRADE 1 AND GRADE 2
S.Y. 2021-2022

Enrollment: Grade 1 Grade 2

Male: 5` Male: 6
Female: 6 Female: 2

Minutes Time Monday Tuesday Wednesday Thursday Friday

10 7:15-7:25 Arrival/ Daily Routine/ Health Break
45 7:25-8:10 MTB-MLE 1 MATH 1 AP 1 ENGLISH 1 PE 1
45 8:10-8:55 Pagbasa ha MUSIC 1 HEALTH 1
MTB-MLE
15 8:55-9:10 RECESS/Handwashing
45 9:10-10:55 FILIPINO 1 ESP 1 ARTS 1 Enrichment Printing of
Modules/LAS
45 10:55-11:40 Pagbasa sa Filipino Reading in English
11:40-1:00 Dismissal/Preparation
45 1:00-1:45 MTB-MLE 2 MATH 2 ENGLISH 2 HEALTH 2 Printing of
45 1:45-2:30 FILIPINO 2 PE 2 Modules/
45 2:30-3:15 ESP 2 AP 2 ARTS 2 MUSIC 2 Construction
of Lesson Log/
Checking of
Modules/LAS
45 3:15-4:00 Pagbasa sa Filipino Reading in English
60 4:00-5:00 Printing of Modules/Dismissal/Cleaning
Total: 445 minutes

Prepared by: Recommending Approval:

ICY DACER NILA C. MOCORRO

Teacher School Head

Approved by:
ALMA C. CABUSOR, Ph.D.
District Supervisor

BLACKBOARD
ENTRAN
 PULANG YUTA ELEMENTARY SCHOOL
S.Y. 2021-2022

PARENT’S PERMIT
FOR FACE TO FACE
LEARNING MODALITY
GRADE 1
S.Y. 2021-2022
 PULANG YUTA ELEMENTARY SCHOOL
S.Y. 2021-2022

GRADE 1
LEARNER’S PROFILE
 PULANG YUTA ELEMENTARY SCHOOL
S.Y. 2021-2022

GRADE 2
LEARNER’S PROFILE

PULANG YUTA ELEMENTARY SCHOOL

S.Y. 2021-2022
 SCHEDULE OF
SANITATION AND
DISINFECTION

PUPIL’S FORM

PULANG YUTA ELEMENTARY SCHOOL

HEALTH DECLARATION FORM

DATE: ________________ TIME: ________

NAME: _____________________________________________ GRADE LEVEL: _____

HOME ADDRESS: _______________________________________________________
CONTACT NUMBER: ____________________________________________________
 YES NO
1. Are you experiencing a. Sore throat
b. Body pains
c. Headache
d. Fever for the past
few days
2. Have you been together or stayed in the same close environment of a
confirmed COVID-19 case?
3. Have you had any contact with anyone with fever, cough, colds and sore
throat in the past 2 weeks?
4. Have you travelled outside of the Philippines in the last 14 days?
5. Have you travelled to any area in the Region 8 aside from your home?
6. Do you have any comorbidities, immunodeficiency or other health risk?

I hereby authorize Pulang Yuta Elementary School to collect and process the data
indicated herein for the purpose of effecting control of the COVID-19 infection. I
understand that any personal information is protected by RA10173 “Data Privacy Act of
2012” and that I am required by RA 11409 “Bayanihan to Heal as One Act” to provide
truthful information.

____________________________________

PULANG YUTA ELEMENTARY SCHOOL

S.Y. 2021-2022
CLASS PROGRAM
GRADE 1 AND 2