Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

STUDENT TESTING AND ADMISSIONS

CSPC-F-STA-12

Post Examination Health Surveillance Form

Instructions: Please continue to follow social distancing and the wearing of face mask even after the exam. You
are required to send an email at the official email address of the Student Testing and Admissions
(testingandadmission@cspc.edu.ph) 15 days after the scheduled examination date. Please provide truthful
information relative to your health status.

Dear CSPC-STA,

Good day! I took the CSPC College Entrance Test last ___________________.
(Date of exam)
I would like to inform you of my health status as of _______________________.
(date)

Name: __________________________________________
Date of Exam: __________________________________________
Control No: __________________________________________

My health status is: (Please check (✓) all relevant items)

have no symptom/s.
with the following symptom/s:
___ fever
___ cough
___ easy fatigability
___ other signs/ symptoms or remarks: _______________

After completing the message, you will receive an acknowledgment and/or further instructions from
CSPC-STA Office.

Thank you for your cooperation and STAY SAFE.

Effectivity Date: December 2022 Rev. 0 Page 1 of 1