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Republic of the Philippines

Department of Education
MIMAROPA REGION
SCHOOLS DIVISION OF PALAWAN

INCIDENT REPORT FORM

Reported by: Date:

Division: Palawan
INCIDENT INFORMATION
Type of Incident: COVID-19 Date and Time of
EXPOSURE Incident: JUNE 3,2021

Location Coron, Palawan

Details of Incident:
As of June 3, 2021 Raymund Gumbilan (learner) stated that he was interacted with her
employer who has Covid-19.

Name/Role/Contact of Parties Involved:


1. RAYMUND GUMBILAN/ STUDENT/ _____________________________
2. _____________________________________________________________________
3. _____________________________________________________________________

Action Taken:

Prepared by: Received by:

MARY GRACE M. HEREDERO GLENDIE LEE PELAYO-BUASAG


Adviser School Information Coordinator

___________________________ ___________________________
Date Date

CORON SCHOOL OF FISHERIES


Bgy. Poblacion 1, Coron, Palawan 5316
Mobile No.: 09063263012/09176342091
Email Address: 301684csof@deped.gov.ph

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