JANUARY 25,2021

EUFEMIA T. GAMUTIN, CESO V

Schools Division Superintendent

Thru: JAY ANN L. PLAZA,MD

Medical Officer III

Dear Ma’am,
Good day!
I am writing to humbly request that I would be allowed to work from home for the next month
due to my pregnancy and as unvaccinated personnel in our school. I recently visited my doctor and
declared me to have a high-risk one due to some abdominal contractions which is not normal during
my stage. She also advised me to reschedule first the plan to be vaccinated with COVID-19 vaccine
due to the situation.
With this, as of the moment, I am declining to be vaccinated for the safety of my pregnancy
and my own health, but I am willing to be vaccinated until further advised by my doctor/ob-gyn.
Rest assured that I will be available at all times either through phone or chat during working
hours. I will also coordinate closely with my direct supervisors/school-head.
Attached herewith are the copy of my medical reports for your reference. I am hoping for your
kind understanding and consideration.

Sincerely yours,
EVANGELINE H. BAISAC
TEACHER 1

Noted by:

NENITA I. REPONTE
HT1-SIC

Recommending Approval:

JAY ANN L. PLAZA,MD

Medical Officer III

Approved by:

EUFEMIA T. GAMUTIN,CESO V
Schools Division Superintendent
 Control No. __________

Work from Home Medical Certificate for Vulnerable sectors

This is to certify that EVANGELINE H. BAISAC, 30 , TEACHER 1
(Complete Name) (Age/Sex) (Position)
of DIOSDADO MACAPAGAL NATIONAL HIGH SCHOOL was diagnosed of having an
(Name of School/ Office)
illness and/or pre-existing medical condition as shown below;

o Cancer
o Chronic Lung Disease
a. Chronic Obstructive Pulmonary Disease (COPD)
b. Asthma (Moderate to Severe)
c. Interstitial Lung Disease
d. Cystic Fibrosis
e. Pulmonary Hypertension
o Dementia or other neurological conditions
o Diabetes Type I & 2
o Heart conditions
a. Heart failure
b. Coronary Artery Disease
c. Cardiomyopathies
d. Hypertension
o HIV infection
o Immunocompromised state
o Liver Disease (i.e. Liver cirrhosis)
o Obesity (BMI >30kg/m2)
o PREGNANCY
o Hemoglobin & other blood disorders
o Solid organ or blood stem cell transplant
o Stroke or Cerebrovascular Disease
o 65 years old and above
o UNVACCINATED
o Others: ______________________

Remarks:
____________________________________________________________________________________________________________
__________________________________________________________________________________This certification is being
issued for his or her request for Work From Home in reference to Division Memorandum No. ________

But may report on site as needed with strict compliance to minimum health safety protocols.

Recommending Approval:

JAY ANN L. PLAZA, MD

Medical Officer III Approved:

EUFEMIA T. GAMUTIN, CESO V

Schools Division Superintendent