CONSENT FORM FOR LEARNERS’ HEALTH ASSESSMENT AND SCREENING

Date: _______________________

I. Data Privacy Notice General head-to-toe assessment is a thorough

The Department of Education (DepEd) shall overall examination performed by health
engage in the collection of health/medical personnel to detect signs and symptoms of
information for the purposes of tracking, illness, physical or behavioral defects or
provision of necessary health/medical abnormality, monitor hygiene practices, and
interventions, and educational purposes. This provide health education.
information shall be processed in accordance
with the provisions of the Data Privacy Act and Vision screening
the Data Privacy Policies of the Department. A non-diagnostic procedure aimed at early
detection and management of vision problems
This information shall be stored and held among learners. This may be done by teachers
confidentially in accordance with the provisions (for Kindergarten learners and non-readers) and
of the Basic Education Act and may only be non-teaching personnel (for Grades 1 and 7)
shared with other government agencies or third who have received appropriate training, school
parties subject to Data sharing agreements and health personnel, or local partners.
data privacy requirements for legitimate
purposes only. Hearing screening
A non-diagnostic procedure intended to identify
For inquiries, requests and concerns regarding learners who may require further evaluation
your data privacy rights, please contact the and management by appropriate healthcare
data privacy compliance officer, team of the professionals.
school, schools division office or regional office
concerned. Oral health assessment
Evaluation of the oral cavity, conducted by
By affixing my signature at the end of this licensed dentists, including inspection of the
document, I hereby consent and authorize the teeth, gums, and other oral tissues to identify
Department of Education to use, collect, and dental and other oral health concerns.
process the information for the purposes of the
above stated. Universal mental health and psychosocial
screening and assessment
In compliance with “Republic Act (RA) 11036 or
the “Mental Health Act”, Universal mental
II. Components of Learner Health health screening refers to the systematic
Assessment and Screening (LHAS) assessment of learners based on their school
performance, behaviors, and social-emotional
Nutritional Assessment functioning. Psychosocial screening aims to
Determining the height and weight of Kinder to identify risk factors that may affect a learner’s
Grade 6 learners to get their nutritional status mental health, emotions, or interactions with
as basis for inclusion to the School-Based other people. It is intended to prevent the
Feeding Program (SBFP). learner’s condition from worsening and to
provide immediate intervention if necessary.
Health history intake and general head-to- The purpose of screening is not to provide
toe assessment clinical diagnosis of mental disorders, but to
Recording of past medical history (allergies, identify at-risk learners and provide early
ongoing medical conditions, past intervention and support, or referral for
surgeries/hospitalization), family medical specialized help if needed.
history, smoking/vaping history, handedness,
immunization status, and other relevant Psychosocial assessment is a guided, semi-
information. structured interview conducted by the School
Counselors and/or other trained personnel on
learners who will be identified as “at-risk.”
III. Consent to Health Assessment and Screening

I, _____________________________________________________, the parent/ parent - substitute/ legal

(Full name)
guardian of _____________________________________________________, _________ years old,
(Full name of learner) (Age (Sex)
Male/Female, _________________________________________________________ learner in
(Grade level)
___________________________________________________________________________________ have been
(Name of school)
properly and fully informed about the details of the learners’ health assessment and screening. I
understand that participation is voluntary and choosing whether to participate or not will have no
effect on the grade, treatment, or care of my child/ward. I am aware that non-participation may
lead to my child/ward being unable to join certain programs and services that require the
information collected in the procedures listed above.
By affixing my signature below, I hereby state that:
Please mark the space with a (✓) and place your signature at the end of this document.

I CONSENT for my child/ward to I DO NOT CONSENT for my

undergo the following child/ward to undergo the
assessments/screening: following assessments/screening:

Nutritional Assessment
Health history intake and
general head-to-toe
assessment
Vision screening

Hearing screening

Oral health assessment

Universal mental health
and psychosocial
screening and
assessment

Signature above Printed Name Date

(Parent/parent-substitute/legal
guardian)
LEARNER’S ASSENT FORM FOR HEALTH ASSESSMENT AND SCREENING
I have been informed of the details of the Learner Health Assessment and Screening and that my
parent/parent-substitute/guardian has given permission for me to participate. My participation is
voluntary and I have been told that I may stop my participation at any time. I understand that If I
choose to participate or not, will not affect my grade, treatment, or care in any way, except in
activities that require the information collected in the procedures listed above.

Signature above Printed Name Date

(Learner)
 PAHINTULOT NG MAGULANG PARA SA HEALTH ASSESSMENT AT SCREENING
Petsa: ________________________

I. Data Privacy Notice Layunin ng pagsusuring ito ang maagang

Ang Department of Education (DepEd) ay pagtuklas at pamamahala ng mga problema sa
mangongolekta ng impormasyong mata ng mga mag-aaral. Hindi nito layuning
pangkalusugan/medikal para sa mga layunin ng magbigay ng diagnosis. Ito ay at maaaring
pagsubaybay, pagbibigay ng kinakailangang gawin ng mga guro (para sa Kindergarten at
mga interbensyon, at mga layuning pang- hindi pa nakababasa) at iba pang empleyado
edukasyon. Ang mga impormasyong ito ay ng DepEd (para sa iba pang baitang) na
ipoproseso alinsunod sa mga probisyon ng Data nakatanggap ng angkop na pagsasanay, health
Privacy Act at ng Data Privacy Policy ng DepEd. personnel, o mga lokal na katuwang.

Ang impormasyong ito ay mananatiling Hearing screening

kumpidensyal alinsunod sa mga probisyon ng Layunin ng pagsusuring ito na tukuyin ang mga
Basic Education Act at maaari lamang ibahagi mag-aaral na maaaring mangailangan ng
sa ibang mga ahensya ng gobyerno o mga komprehensibong pagsusuri ng tenga at
ibang partido na napapailalim sa Data Sharing pandinig o karagdagang pamamahala mula sa
Agreement para sa mga lehitimong layunin espesyalista.
lamang, alinsunod sa mga alituntunin ng data
privacy. Oral health assessment
Pagsusuri sa bunganga na isinasagawa ng mga
Para sa mga katanungan, kahilingan, at lisensyadong dentista. Kasama rito ang
alalahanin tungkol sa iyong mga karapatan sa inspeksyon sa mga ngipin, gilagid, at iba pang
privacy ng data, mangyaring makipag-ugnayan bahagi ng bibig upang matukoy ang mga sirang
sa data privacy compliance officer, team ng ngipin at iba pang mga sakit sa bunganga.
paaralan, schools division office, o regional
office na kinauukulan. Universal mental health and psychosocial
screening and assessement
Sa pamamagitan ng aking paglagda, Ang “Universal Mental Health Screening” ay
pinahihintulutan ko ang DepEd na gamitin, isang paraan ng regular at sistematikong
kolektahin, at iproseso ang impormasyon para pagsuri sa kalagayan ng mga mag-aaral
sa mga layuning nakasaad sa itaas. pagdating sa kanilang pag-aaral, asal, at
pakikitungo sa kapwa. Layunin nitong matukoy
kung sino ang posibleng may pinagdaraanan o
II. Mga Bahagi ng Health Assessment maaaring magkaroon ng problema sa pag-iisip
at Screening o emosyon (mental health) upang sila ay
maagang mabigyan ng nararapat na tulong. Ito
Nutritional Assessment ay sa pamamagitan ng suporta, paggabay, o
Pagsukat ng tangkad at timbang ng mag-aaral pag-refer sa espesyalista kung kinakailangan.
upang makuha ang kanyang nutritional status.
Ang “Psychosocial Screening” ay layuning
Health History Intake and General Head- matukoy kung may posibleng mga problema o
to-toe Assessment panganib na maaring makaapekto sa pag-iisip,
Pagtatala ng impormasyong medikal (tulad ng damdamin o pakikitungo sa ibang tao ang isang
allergy, sakit, nakaraang operasyon/pagka- mag-aaral. Ito ay upang maiwasan ang paglala
ospital), impormasyong medikal ng pamilya, ng kondisyon ng mag-aaral, at makapagbigay
kasaysayan ng paninigarilyo/vaping, kamay na ng agarang tulong ayon sa kanyang
panulat, status ng pagbabakuna, at iba pang pangangailangan.
nauugnay na impormasyon.
Hindi layunin ng screening na magbigay ng
Ang pangkalahatang assessment ay isang tiyak na diagnosis ng sakit sa pag-iisip, kundi
masusing pagsusuri na isinagawa ng mga tukuyin lamang kung sino ang maaring
health personnel upang makita ang mga nanganganib at nangangailangan ng agarang
sintomas ng karamdaman, madetetekta ang tulong.
mga kakaibang katangian sa pisikal na anyo o
sa pagkilos, masubaybayan ang kalinisan ng Ang “Psychosocial Assessment” ay isang uri ng
mag-aaral, at magbahagi ng kaalaman na pag-uusap o panayam upang matukoy kung
nauukol sa kalusugan. sino sa mag-aaral ang "at-risk" o posibleng may
pinagdaraanan sa pag-iisip, damdamin, o
pakikitungo sa ibang tao. Ito ay ginagawa ng

Vision screening
School Counselor or iba pang personnel ng paaralan na may sapat na pagsasanay.

III. Pahintulot para sa Health Assessment and Screening

Ako si _____________________________________________________________________, ang

(Buong Pangalan)
magulang/tagapangalaga ni ______________________________________, ______ taong gulang,
(Buong Pangalan ng mag-aaral) (Kasarian)
lalaki/babae _______________ sa
(Baitang) (Paaralan
____________________________________________________________________________,
) ay naiintindihan nang
wasto at ganap health assessment at screening para sa mga mag-aaral. Alam ko na ang paglahok
ng aking anak/alaga ay boluntaryo at ang mag-aaral/magulang/tagapangalaga ay may karapatang
bawiin ang pahintulot ngayon o kailanman sa pamamagitan ng pagpapadala ng kasulatan sa
eskwelahan, nang walang epekto sa grado o kalidad ng matatangap na serbisyo ng aking
anak/alaga. Naiintindihan ko na ang hindi paglahok ay maaaring humantong sa hindi pagkasali ng
aking anak/alaga sa mga partikular na programa at serbisyo na nangangailangan ng
impormasyong nakolekta sa mga pamamaraang nakalista sa itaas.

Sa pamamagitan ng paglalagay ng aking lagda sa ibaba, ipinapahayag ko na:

PINAHIHINTULUTAN KO HINDI KO PINAHIHINTULUTAN

ang aking anak/alaga na ang aking anak/alaga na
sumailalim sa learner health sumailalim sa learner health
assessment at screening assessment at screening
Nutritional Assessment
Health history intake and
general head-to-toe
assessment
Vision screening

Hearing screening

Oral health assessment

Universal mental health and

psychosocial screening and
assessment
Markahan ang kaukulang checkbox ng (✓) at ilagay ang lagda sa dulo ng dokumento.

Pangalan at Lagda Petsa

(Magulang)

PAGSANG-AYON NG MAG-AARAL PARA SA HEALTH ASSESSMENT AT SCREENING

Naipaalam sa akin ang mga detalye ng Learner Health Assessment and Screening at na ang aking
magulang/tagapangalaga ay nagbigay ng pahintulot para sa akin na lumahok. Ang aking
pakikilahok ay boluntaryo at sinabihan ako na maaari kong ihinto ang aking paglahok anumang
oras. Naiintindihan ko na ang aking desisyong makilahok o hindi ay hindi makakaapekto sa aking
grado, paggamot, o pangangalaga sa anumang paraan, maliban na lamang sa mga aktibidad na
nangangailangan ng impormasyong nakolekta sa mga pamamaraang nakalista sa itaas.

Pangalan at Lagda Petsa

(Mag-aaral)