Republic of the Philippines

Department of Education
Region II – Cagayan Valley
Schools Division of Cagayan
Abariongan National High School
CONTINGENCY PLAN
(ASSESSMENT FORM)
Name: Gender: Male Female
Grade and Section: Birthday:
Address: Adviser:
Contact No.: E-mail: Quarter: SY:
Date Reported Report Intended Details of Action to be Taken Remarks of Action Taken
for Concern
Need Dialogue Ongoing
Consultation
Progress Accomplished
Remedial Class
Achievement Home Visitation Details:

Assembly/Forum
Need Dialogue Ongoing
Consultation
Progress Accomplished
Remedial Class
Achievement Home Visitation Details:

Assembly/Forum
Need Dialogue Ongoing
Consultation
Progress Accomplished
Remedial Class
Achievement Home Visitation Details:

Assembly/Forum
Need Dialogue Ongoing
Consultation
Progress Accomplished
Remedial Class
Achievement Home Visitation Details:
Assembly/Forum

Remarks:

Address: Abariongan Ruar, Sto. Niño, Cagayan

Telephone Nos.: 09957246843
Email Address: abariongannhs@gmail.com/306006@deped.gov.ph
Website: https://sites.google.com/deped.gov.ph/abariongan-nhs
 Republic of the Philippines
Department of Education
Region II – Cagayan Valley
Schools Division of Cagayan
Abariongan National High School

COVID-19 RISK ASSESSMENT

CP #: Temp: Date:
Name:
Age/Sex:
Residence:
Agency/Department:
Unit to visit:

IF YES, please indicate present maintenance

PRESENT MEDICAL CONDITION YES NO
medications

Hypertension

Diabetes

Kidney Diseases

Cardiovascular Disease

Autoimmune Diseases
(e.g. Lupus)

Others (please specify):

*For female employees: Are you

pregnant?

YES NO

1. Are you residing in a barangay with known

COVID-19 case?
(If yes, please specify)

2. Do you have exposure to a Suspect, Probable or

Confirmed COVID-19 patient?

3. At present, do you experience any of the

following:

a. Fever

b. Sore throat

c. Cough

d. Difficulty of Breathing

e. Diarrhea

NOTE: Please answer each question/statement as honest as possible. All answers will be kept confidential. This checklist has been prepared
with the aim of identifying personnel, parents and visitors who belong to the vulnerable sector or those people who are at high risk of
transmission and severe illness once infected with COVID-19. Results from the latest annual physical exam conducted including but not
limited to this checklist shall be considered in the crafting of the Office Human Resource Operational Plan. Thank You.

Address: Abariongan Ruar, Sto. Niño, Cagayan

Telephone Nos.: 09957246843
Email Address: abariongannhs@gmail.com/306006@deped.gov.ph
Website: https://sites.google.com/deped.gov.ph/abariongan-nhs
 Republic of the Philippines
Department of Education
Region II – Cagayan Valley
Schools Division of Cagayan
Abariongan National High School

Address: Abariongan Ruar, Sto. Niño, Cagayan

Telephone Nos.: 09957246843
Email Address: abariongannhs@gmail.com/306006@deped.gov.ph
Website: https://sites.google.com/deped.gov.ph/abariongan-nhs