Republic of the Philippines

Department of Education
Region III – Central Luzon
Schools Division Office of Pampanga
District of San Simon
San Nicolas Elementary School
San Nicolas, San Simon, Pampanga
CHECKLIST FOR MOVS/DOCS FOR LIMITED FACE-TO-FACE
SCHOOL ___________________________ Date ___________________
School ID _________________________
Name of School Head _________________
Designation __________________________

No. Indicators Evident Not Evident Remarks

1. Parent Consent
2. Pupils Profile
3. Health Form
4. Classroom daily Health Monitoring
Tool
5. Summary of Health Status of
Personnel
6. Municipal Concurrence
7. Barangay Concurrence
8. Contingency Plan
9. MOA Face to Face
10. School Action Plan for
Implementation of Face-to-Face
11. Face to Face Class Program
12. Orientation on F2F Modality

District Composite Team

___________________________________ _______________________________
District DRRM Leader District Property Custodian

___________________________________ ___________________________________
Division Nurse -In-charge in the District Principal In Charge of Health

JULIETA V. SAGUM
Public Schools District Supervisor

Address: San Nicolas, San Simon, Pampanga

Facebook: SanNicolas ElemSchool Snes
E-mail Address: Sannicolas/es@yahoo.com