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COVID-19 Quarantine Evaluation Report

This memo provides a quarantine evaluation report and return-to-work clearance for a PCSO personnel who was a confirmed or probable COVID-19 case. It includes identifying information for the individual, their vaccination and health status, recommended quarantine/isolation period based on DOH guidelines, completion date of hospitalization/isolation/quarantine, and clearance for return to work with approvals from the employee's supervisor and medical officer. The purpose is to document the quarantine and clearance of the individual as required by PCSO policy following a COVID infection.

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137 views2 pages

COVID-19 Quarantine Evaluation Report

This memo provides a quarantine evaluation report and return-to-work clearance for a PCSO personnel who was a confirmed or probable COVID-19 case. It includes identifying information for the individual, their vaccination and health status, recommended quarantine/isolation period based on DOH guidelines, completion date of hospitalization/isolation/quarantine, and clearance for return to work with approvals from the employee's supervisor and medical officer. The purpose is to document the quarantine and clearance of the individual as required by PCSO policy following a COVID infection.

Uploaded by

matthew domingo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

MEMO COVID-19-Dept/Branch/Office-month/day/year(00/00/0000)-#xxxx ANNEX B

FOR : HRD / MSD


THRU : OAGM, ADMIN
OAGM, Charity
OAGM (Sector. If neither of the above)
FROM : Dept/Branch/Office Official/Authorized Representative

RE : QUARANTINE EVALUATION REPORT / RTW CLEARANCE


(FOR PCSO COVID CASE)
(PUM/PUI OR POSITIVE)
DATE : month-day-year
=====================================================================================
References: 1. DOH Department Memo # 2022-0013 January 14, 2022
2. MO-2022-012: AMENDMENTS TO THE PROTOCOL ON MANAGEMENT OF COVID 19-CASES, January 26,
2022 (Memorandum Order No. 02-OGM-013)
Identifying Data & Status of PCSO Personnel:
Name:____________________________________________________Age:_____Sex:_______
Contact Number: __________________________________ Department/Branch/Office: __________________________

Vaccination Status Date Brand

Full 1st Dose____________________________ 1st Dose____________________________


Partial 2nd Dose___________________________ 2nd Dose___________________________
Booster Booster____________________________ Booster____________________________
Unvaccinated

NOTES: Date of last contact with Index Case/onset of


symptoms/positive test results, date
specimen collected (please specify): Day 0

HEALTH STATUS: Home


Positive Hospital
Probable (PUI/Symptomatic) Quarantine Facility
Suspect (PUM/Asymptomatic) Temporary Treatment & Monitoring
Facility

___________________________________ _______________________________________
NAME & SIGNATURE OF EMPLOYEE NAME & SIGNATURE OF SUPERVISOR/BM/DM

RECOMMENDED QUARANTINE/ISOLATION:
Based on DOH GUIDELINES APPLICABLE FOR CASE: (please see guidelines/info graphics)*

Vaccinated Asymptomatic 5 days 7 days


Unvaccinated Mild 10 days 14 days
Moderate 21 days
Severe/Critical

__________________________________________________

JOSE BERNARDO H. GOCHOCO JR., MD


Manager, Medical Services Department

Cc : Medical Services Department

*Submit Initial Quarantine Evaluation Report/Return-to-work via PCSO Corporate E-mail ([email protected])*
FOR RETURN-TO WORK CLEARANCE:

*Please submit to MSD self-monitoring sheet for issuance of RTW Clearance.

COMPLETION DATE OF HOSPITALIZATION/ISOLATION/QUARANTINE:

DATE: REMARKS:

RELEASE STATUS: (Please see guidelines/infographics) *

5 days 7 days 10 days 14 days 21 days

RETURN-TO-WORK CLEARANCE ISSUED:


DATE:_______________________
TIME:_______________________

RECOMMENDING APPROVAL: APPROVED:

_______________________________ _______________________________
Name & Signature of supervisor/BM/DM ZELDA A. GANANCIAL, MD
Medical Officer VI, MSD-PLD

*Submit to HRD a copy of RTW Clearance for leave monitoring

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