Republic of the Philippines Republic of the Philippines

Department of Education Department of Education

Region VII - Central Visayas Region VII - Central Visayas
DIVISION OF CEBU PROVINCE DIVISION OF CEBU PROVINCE
EMPLOYEE/VISITOR'S SCREENING QUESTIONNAIRE EMPLOYEE/VISITOR'S SCREENING QUESTIONNAIRE

(Please fill in your answer) Temperature :_________ (Please fill in your answer) Temperature :_________
Name : ___________________________________ Position : _____________ Sex: ______ Name : ___________________________________ Position : _____________ Sex: ______
Residence : _______________________________________ Age : _____ Residence : _______________________________________ Age : _____
Contact Number: ______________________________ Contact Number: ______________________________

Status : Teaching Personnel:____ Non-teaching Personnel: _____ Status : Teaching Personnel:____ Non-teaching Personnel: _____
Parent :_____ Student : ____ Visitor : _____ Parent :_____ Student : ____ Visitor : _____
[If Employee (Teacher/Administrator/Staff) [If Employee (Teacher/Administrator/Staff)
Division Office Personnel Section : ______________ Division Office Personnel Section : ______________
District/School Personnel School : ______________________ District : ___________ District/School Personnel School : ______________________ District : ________________

Yes No Yes No
1. Are you experiencing any of the following symptoms: sore throat, body pains, headache. Cough, 1. Are you experiencing any of the following symptoms: sore throat, body pains, headache. Cough,
runny nose or fever for the past few days? (Nakasinati ba ka og bisan asa ani nga mga sintomas: sakit sa runny nose or fever for the past few days? (Nakasinati ba ka og bisan asa ani nga mga sintomas: sakit sa
tutunlan, sakit sa kalawasan, ubo, sip-on o hilanat sa miaging mga adlaw? tutunlan, sakit sa kalawasan, ubo, sip-on o hilanat sa miaging mga adlaw?

2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? 2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
(Nakakuyog ba kag tawo or katrabaho sa usa ka kompirmadong naay COVID-19/naay impeksyon sa (Nakakuyog ba kag tawo or katrabaho sa usa ka kompirmadong naay COVID-19/naay impeksyon sa
corona virus corona virus

3. Have you had any contact with anyone with fever, cough. Colds, and sore throat in the past 2 3. Have you had any contact with anyone with fever, cough. Colds, and sore throat in the past 2
weeks? (Naa ba kay nakuyogt nga naay hilanat, ubo, sip-on ug sakit sa tutunlan sa niaging duha ka weeks? (Naa ba kay nakuyogt nga naay hilanat, ubo, sip-on ug sakit sa tutunlan sa niaging duha ka
semana?) semana?)

4. Have you travelled outside of the Philippines in the last 14 days? (Nakalarga ba ka sa gawas sa 4. Have you travelled outside of the Philippines in the last 14 days? (Nakalarga ba ka sa gawas sa
Pilipinas sa niaging 14 ka adlaw?) Pilipinas sa niaging 14 ka adlaw?)
5. Have you ever been confirmed as COVID-19 positive? If yes, please note the exact date. (Nadeklara 5. Have you ever been confirmed as COVID-19 positive? If yes, please note the exact date. (Nadeklara
ba ka nga positibo sa COVID-19? (Kon oo, palihug ug butang sa petsa.) ba ka nga positibo sa COVID-19? (Kon oo, palihug ug butang sa petsa.)

6. Have you ever been declared as a suspect or you have had a face to face contact, cared for or lived 6. Have you ever been declared as a suspect or you have had a face to face contact, cared for or lived
in the same house with a person confirmed as COVID-19 positive? (Nakasulay ba ka nga dideklarar kang in the same house with a person confirmed as COVID-19 positive? (Nakasulay ba ka nga dideklarar kang
positibo pagka COVID-19 positive o personal ka nga nakaatubang , alima o puyo kuyog og tawo nga positibo pagka COVID-19 positive o personal ka nga nakaatubang , alima o puyo kuyog og tawo nga
kumpirmado nga positibo sa COVID-19?) kumpirmado nga positibo sa COVID-19?)

7. Have you stayed/travelled in an area with high risk as identified by authorities, or placed under ECQ? 7. Have you stayed/travelled in an area with high risk as identified by authorities, or placed under ECQ?
(Nakapundo o suroy ba ka og lugar nga taas og risgo Sa COVID-19 o napahisulod sa ECQ? (Nakapundo o suroy ba ka og lugar nga taas og risgo Sa COVID-19 o napahisulod sa ECQ?

8. Are you currently residing in an area with high risk as identified by authorities, or placed under ECQ? 8. Are you currently residing in an area with high risk as identified by authorities, or placed under ECQ?
(Naa ba ka nagpuyo karon sa usa ka lugar nga taas og risgo sa COVID-19 o napahisulod sa ECQ? (Naa ba ka nagpuyo karon sa usa ka lugar nga taas og risgo sa COVID-19 o napahisulod sa ECQ?

I hereby authorized Department of Education, to collect and process data indicated herein for the I hereby authorized Department of Education, to collect and process data indicated herein for the
purpose of effecting control of the COVID-19 infection. I purpose of effecting control of the COVID-19 infection. I

understand that my personal information is protected by RA 10173, Data Privacy ACT of 2012, and that understand that my personal information is protected by RA 10173, Data Privacy ACT of 2012, and that
I am required by RA 11469, Bayanihan to Heal as I am required by RA 11469, Bayanihan to Heal as
One Act, to provide truthful information. One Act, to provide truthful information.

Signature over Printed Name : ____________________________________________ Date : __________ Signature over Printed Name : ____________________________________________ Date : __________

Republic of the Philippines Republic of the Philippines

Department of Education Department of Education
Region VII - Central Visayas Region VII - Central Visayas
DIVISION OF CEBU PROVINCE DIVISION OF CEBU PROVINCE
EMPLOYEE/VISITOR'S SCREENING QUESTIONNAIRE EMPLOYEE/VISITOR'S SCREENING QUESTIONNAIRE
(Please fill in your answer) Temperature :_________ (Please fill in your answer) Temperature :_________
Name : ___________________________________ Position : _____________ Sex: ______ Name : ___________________________________ Position : _____________ Sex: ______
Residence : _______________________________________ Age : _____ Residence : _______________________________________ Age : _____
Contact Number: ______________________________ Contact Number: ______________________________
Status : Teaching Personnel:____ Non-teaching Personnel: _____ Status : Teaching Personnel:____ Non-teaching Personnel: _____
Parent :_____ Student : ____ Visitor : _____ Parent :_____ Student : ____ Visitor : _____
[If Employee (Teacher/Administrator/Staff) [If Employee (Teacher/Administrator/Staff)
Division Office Personnel Section : ______________ Division Office Personnel Section : ______________
District/School Personnel School : ______________________ District : ___________ District/School Personnel School : ______________________ District : ________________

Yes No Yes No
1. Are you experiencing any of the following symptoms: sore throat, body pains, headache. Cough, 1. Are you experiencing any of the following symptoms: sore throat, body pains, headache. Cough,
runny nose or fever for the past few days? (Nakasinati ba ka og bisan asa ani nga mga sintomas: sakit sa runny nose or fever for the past few days? (Nakasinati ba ka og bisan asa ani nga mga sintomas: sakit sa
tutunlan, sakit sa kalawasan, ubo, sip-on o hilanat sa miaging mga adlaw? tutunlan, sakit sa kalawasan, ubo, sip-on o hilanat sa miaging mga adlaw?

2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case? 2. Have you worked together or stayed in the same close environment of a confirmed COVID-19 case?
(Nakakuyog ba kag tawo or katrabaho sa usa ka kompirmadong naay COVID-19/naay impeksyon sa (Nakakuyog ba kag tawo or katrabaho sa usa ka kompirmadong naay COVID-19/naay impeksyon sa
corona virus corona virus

3. Have you had any contact with anyone with fever, cough. Colds, and sore throat in the past 2 3. Have you had any contact with anyone with fever, cough. Colds, and sore throat in the past 2
weeks? (Naa ba kay nakuyogt nga naay hilanat, ubo, sip-on ug sakit sa tutunlan sa niaging duha ka weeks? (Naa ba kay nakuyogt nga naay hilanat, ubo, sip-on ug sakit sa tutunlan sa niaging duha ka
semana?) semana?)

4. Have you travelled outside of the Philippines in the last 14 days? (Nakalarga ba ka sa gawas sa
Pilipinas sa niaging 14 ka adlaw?)
5. Have you ever been confirmed as COVID-19 positive? If yes, please note the exact date. (Nadeklara
ba ka nga positibo sa COVID-19? (Kon oo, palihug ug butang sa petsa.)
6. Have you ever been declared as a suspect or you have had a face to face contact, cared for or lived
in the same house with a person confirmed as COVID-19 positive? (Nakasulay ba ka nga dideklarar kang
positibo pagka COVID-19 positive o personal ka nga nakaatubang , alima o puyo kuyog og tawo nga
kumpirmado nga positibo sa COVID-19?)
4. Have you travelled outside of the Philippines in the last 14 days? (Nakalarga ba ka sa gawas sa
Pilipinas sa niaging 14 ka adlaw?)
5. Have you ever been confirmed as COVID-19 positive? If yes, please note the exact date. (Nadeklara
ba ka nga positibo sa COVID-19? (Kon oo, palihug ug butang sa petsa.)
6. Have you ever been declared as a suspect or you have had a face to face contact, cared for or lived
in the same house with a person confirmed as COVID-19 positive? (Nakasulay ba ka nga dideklarar kang
positibo pagka COVID-19 positive o personal ka nga nakaatubang , alima o puyo kuyog og tawo nga
kumpirmado nga positibo sa COVID-19?)

7. Have you stayed/travelled in an area with high risk as identified by authorities, or placed under ECQ? 7. Have you stayed/travelled in an area with high risk as identified by authorities, or placed under ECQ?
(Nakapundo o suroy ba ka og lugar nga taas og risgo Sa COVID-19 o napahisulod sa ECQ? (Nakapundo o suroy ba ka og lugar nga taas og risgo Sa COVID-19 o napahisulod sa ECQ?

8. Are you currently residing in an area with high risk as identified by authorities, or placed under ECQ? 8. Are you currently residing in an area with high risk as identified by authorities, or placed under ECQ?
(Naa ba ka nagpuyo karon sa usa ka lugar nga taas og risgo sa COVID-19 o napahisulod sa ECQ? (Naa ba ka nagpuyo karon sa usa ka lugar nga taas og risgo sa COVID-19 o napahisulod sa ECQ?

I hereby authorized Department of Education, to collect and process data indicated herein for the I hereby authorized Department of Education, to collect and process data indicated herein for the
purpose of effecting control of the COVID-19 infection. I purpose of effecting control of the COVID-19 infection. I
understand that my personal information is protected by RA 10173, Data Privacy ACT of 2012, and that understand that my personal information is protected by RA 10173, Data Privacy ACT of 2012, and that
I am required by RA 11469, Bayanihan to Heal as I am required by RA 11469, Bayanihan to Heal as
One Act, to provide truthful information. One Act, to provide truthful information.

Signature over Printed Name : ____________________________________________ Date : __________ Signature over Printed Name : ____________________________________________ Date : __________