Republic of the Philippines

Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR
Cagwait District
Aras-Asan, Cagwait, Surigao del
School: ________________________________

CLASSROOM DAILY HEALTH MONITORING TOOL FOR COVID -19

GRADE LEVEL: Section:

Instruction: Write under each column date the code(s) of the Symprtom(s) observed in the learner during the routine inspection, during the conduct of the
class, or as reported by the learner or their classmates. Refer to the list of symptoms below and their respective codes:

Fv - Fever F/T fatigue/ tiredness LoA - loss of Appetite R- Rashes

C- Cough ST- Sorethoat N- Nausea LoS- Loss of smell
HA- Headache C/RN Colds/ runny nose D- Diarrhea Others

SYMPTOMS OBSERVED/ REPORTED

NAME MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
DATE: DATE: DATE: DATE: DATE:

Note: As soon as any of the listed symptoms is observed among the any of the learners, the teacher is expected to send the learner to the School Clinic immediately for the
proper management by the School Clinic teacher or Health Personnel.

Submitted by: Noted:

JENEFER B. ACQUIATAN
Classroom adviser Clinic Teacher/ Nurse
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR
Cortes District
Cortes, Surigao del Sur
School: Matho Integrated School

SUMMARY OF HEALTH STATUS OF PERSONNEL AND LEARNERS

For the Month of : _____________________________

CATEGORY GRADE SYMPTOM(S) ACTION TAKEN COVID-19 STATUS PER

DATE REPORTED REFERRED TO FOLLOW-UP
( PERSONNEL/ LEARNER) LEVEL/SECTION OBSERVED/ REPORTED
NAME

Note: Every End of the month copy of this report should be submitted to District Office / District Clinic

Prepared by: Noted:

JENEFER B. ACQUIATAN MARIA ELENA F. MORALES,Ed.D.
Clinic Teacher School Head
 Republic of the Philippines
Department of Education
Caraga Region
SCHOOLS DIVISION OF SURIGAO DEL SUR
Cortes District
Cortes, Surigao del Sur
School: Matho Integrated School
LOGSHEET FOR SCHOOL CLINIC AND SCHOOL ISOLATION ROOM
Treatment Adminitered By
Chief Complaint(s) Doctor's Order Remarks
Follow-Up Status
Time Reason(s) for the clinic visit/ ( To be initiated by the Medical Officer
upon visit/ Supported by the Doctor
Date Name Age Sex Grade/ Sec Teacher/ Adviser reported symptom(s)
admitted Prescription/ Instruction Slip
( Indicate how the instruction of the doctor ( As needed,
were followed, as well as th other instruction
taken; ordered to return to e.g classroom, date/Status)
what time reported to BHERT, specify
contact number; informed the parent about
the instruction, fetched by; etc.

Administer Treatment Ex. Paracetamol 5ml, given at 10:30 Am

Contact the Parent

Refer to Health facility

Report to BHERT