REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN
MUNICIPALITY OF NORZAGARAY
BARANGAY FRIENDSHIP VILLAGE RESOURCES
OFFICE OF THE BARANGAY CHAIRMAN

COVID-19 BARANGAY HEALTH EMERGENCY AND SURVEILLANCE TEAM (BHERT)

CERTIFICATION

DATE: TIME:

BARANGAY:
NAME RHM:

PERSONAL AND MEDICAL INFORMATION

N:
NAME:
AGE: SEX: STATUS:
CONTACT No:
KNOW MEDICAL CONTION/s:

BHERT EXPOSURE ASSESSMENT

(Please Check the aapproriate answer)
Yes ( ) No ( ) Is the Barangay and residential Address of the person identified above
INCLUDED in the list of Households being monitored with COVID19 Case?
Yes ( ) No ( ) Is the name of the person identified above INCLUDED in the List of
Persons being monitored in the Barangay as PUI or CONFIRMED,
PROBABLE or SUSPECT COVID19 Case?

I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE ARE CERTIFIED TRUE AND
CORRECT.

HON. CARLITO DC. TEBOSO ____________________

Barangay Captain Date and Time