Republic of the Philippines Republic of the Philippines Republic of the Philippines

Department of Education Department of Education Department of Education

REGION VI – WESTERN VISAYAS REGION VI – WESTERN VISAYAS REGION VI – WESTERN VISAYAS
SCHOOLS DIVISION OFFICE OF KABANKALAN CITY SCHOOLS DIVISION OFFICE OF KABANKALAN CITY SCHOOLS DIVISION OFFICE OF KABANKALAN CITY
D.C. GURRUCHARRI MEMORIAL SCHOOL D.C. GURRUCHARRI MEMORIAL SCHOOL D.C. GURRUCHARRI MEMORIAL SCHOOL
Sitio Overflow, Brgy. Hilamonan, Kabankalan City, neg. occ. Sitio Overflow, Brgy. Hilamonan, Kabankalan City, neg. occ. Sitio Overflow, Brgy. Hilamonan, Kabankalan City, neg. occ.

HEALTH SCREENING FORM HEALTH SCREENING FORM HEALTH SCREENING FORM

Name: ______________________________________________________ Name: ______________________________________________________ Name: ______________________________________________________

Cellular Number: __________________________ Body Temp.: _________ Cellular Number: ___________________________ Body Temp.: _________ Cellular Number: __________________________ Body Temp.: _________

Reason for entry: Reason for entry: Reason for entry:

______________________________________________________________ ______________________________________________________________ ______________________________________________________________

Questions: YES NO Questions: YES NO Questions: YES NO

1. Have you travelled internationally in the last 14 days?
2. Have you been in contact in the last 14 days with
someone who is confirmed to have COVID-19
3. Are you currently suffering from any of the following
symptoms?
a. Fever
b. Cough
1. Have you travelled internationally in the last 14 days?
2. Have you been in contact in the last 14 days with
someone who is confirmed to have COVID-19
3. Are you currently suffering from any of the following
symptoms?
a. Fever
b. Cough
1. Have you travelled internationally in the last 14 days?
2. Have you been in contact in the last 14 days with
someone who is confirmed to have COVID-19
3. Are you currently suffering from any of the following
symptoms?
a. Fever
b. Cough

c. Sore Throat c. Sore Throat c. Sore Throat

d. Body Pains / Headache d. Body Pains / Headache d. Body Pains / Headache

e. Shortness of Breath e. Shortness of Breath e. Shortness of Breath

DECLARATION DECLARATION DECLARATION

I hereby declare to the best of my knowledge that the information I hereby declare to the best of my knowledge that the information I hereby declare to the best of my knowledge that the information
disclosed is correct at the time of completion. I further undertake to inform disclosed is correct at the time of completion. I further undertake to inform disclosed is correct at the time of completion. I further undertake to inform
the D.C. GURRUCHARRI MEMORIAL SCHOOL should I be diagnosed with the D.C. GURRUCHARRI MEMORIAL SCHOOL should I be diagnosed with the D.C. GURRUCHARRI MEMORIAL SCHOOL should I be diagnosed with
COVID-19 within the next 14 days to facilitate contact tracing. COVID-19 within the next 14 days to facilitate contact tracing. COVID-19 within the next 14 days to facilitate contact tracing.

______________________________________ ______________________________________ ______________________________________

Date and Signature Date and Signature Date and Signature

D.C. Gurrucharri Memorial School

D.C. Gurrucharri Memorial School Sitio Overflow, Brgy. Hilamonan, Kabankalan City, Negros Occidental D.C. Gurrucharri Memorial School
Sitio Overflow, Brgy. Hilamonan, Kabankalan City, Negros Occidental dcgurrucharri@gmail.com Sitio Overflow, Brgy. Hilamonan, Kabankalan City, Negros Occidental
dcgurrucharri@gmail.com dcgurrucharri@gmail.com