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    Health Checklist: Sta. Elena High School

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    Anarica Mae Mendoza
    This document is a health checklist from Sta. Elena High School in the Philippines that collects information such as name, temperature, symptoms, travel history, and potential exposure to COVID-19 cases from students, staff, and visitors. It asks if the individual has experienced symptoms or been in contact with confirmed COVID-19 cases, traveled outside of the Philippines or areas in NCR, and been tested for COVID-19. The individual's signature is required to authorize the collection and processing of this health data.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Health Checklist: Sta. Elena High School

    Uploaded by

    Anarica Mae Mendoza
    78 views1 page
    This document is a health checklist from Sta. Elena High School in the Philippines that collects information such as name, temperature, symptoms, travel history, and potential exposure to COVID-19 cases from students, staff, and visitors. It asks if the individual has experienced symptoms or been in contact with confirmed COVID-19 cases, traveled outside of the Philippines or areas in NCR, and been tested for COVID-19. The individual's signature is required to authorize the collection and processing of this health data.

    Original Description:

    deped health checklist

    Original Title

    Health-Checklist-for-Parents

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    © © All Rights Reserved

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    This document is a health checklist from Sta. Elena High School in the Philippines that collects information such as name, temperature, symptoms, travel history, and potential exposure to COVID-19 cases from students, staff, and visitors. It asks if the individual has experienced symptoms or been in contact with confirmed COVID-19 cases, traveled outside of the Philippines or areas in NCR, and been tested for COVID-19. The individual's signature is required to authorize the collection and processing of this health data.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    78 views1 page

    Health Checklist: Sta. Elena High School

    Uploaded by

    Anarica Mae Mendoza
    This document is a health checklist from Sta. Elena High School in the Philippines that collects information such as name, temperature, symptoms, travel history, and potential exposure to COVID-19 cases from students, staff, and visitors. It asks if the individual has experienced symptoms or been in contact with confirmed COVID-19 cases, traveled outside of the Philippines or areas in NCR, and been tested for COVID-19. The individual's signature is required to authorize the collection and processing of this health data.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    REPUBLIC OF THE PHILIPPINES

    National Capital Region

    STA. ELENA HIGH SCHOOL


    STA. ELENA MARIKINA CITY TEL. NO. 8646-9793 8682-3568

    Health Checklist
    Temperature: Time taken:

    Name: ______________________________________ Sex: ___________ Age: ________


    Address: ______________________________________________________
    Office/Department: Contact Number:
    *for VISITORS, fill in company details below:
    Person to visit:
    Office to visit:
    Name: Name of student: Grade & Sec:
    If parent/ guardian

    PARTICULARS YES NO
    a) Fever (Temp. >37.5◦C )
    b) Cough/ colds
    1. Are you
    c) Sore throat
    experiencing
    d) Body pains
    the following
    e) Headache
    within the past f) Diarrhea/nausea/vomiting
    2 weeks: g) Difficulty of Breathing/ Shortness of Breath
    h) Loss of sense of smell/taste
    2. Have you worked together or stayed in the same close environment of a confirmed COVID - 19
    case?

    3.Have you travelled outside of the Philippines in the last 14 days?


    If yes, please specify. ______________________________________
    4. Have you travelled to any area in NCR aside from your home?
    If yes, please specify. ___________________________________
    5. Have you been recently tested for COVID-19? If yes,
    Date of test: _________________ Result: _______________
    I hereby authorize Sta. Elena High School to collect and process the data indicated herein for the purpose of effective control of
    the COVID-19 infection. I 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 One Act, to provide truthful information.

    Signature: Date:

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