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COVID-19 Health Survey for Educators

This document appears to be a health survey form for employees of the Department of Education Region IV-A Calabarzon Schools Division of Batangas. It collects personal information and asks questions to screen for COVID-19 symptoms, close contact with COVID-19 patients, travel history, and history of being a suspected, probable or confirmed COVID-19 case in the last 14 days. Respondents are asked to provide yes or no answers.

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Lara Denise Breiz
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92 views2 pages

COVID-19 Health Survey for Educators

This document appears to be a health survey form for employees of the Department of Education Region IV-A Calabarzon Schools Division of Batangas. It collects personal information and asks questions to screen for COVID-19 symptoms, close contact with COVID-19 patients, travel history, and history of being a suspected, probable or confirmed COVID-19 case in the last 14 days. Respondents are asked to provide yes or no answers.

Uploaded by

Lara Denise Breiz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

Republic of the Philippines Republic of the Philippines

Department of Education Department of Education


REGION IV-A CALABARZON REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS SCHOOLS DIVISION OF BATANGAS
   
PERSONAL INFORMATION PERSONAL INFORMATION
FIRST FIRST
NAME NAME
MIDDLE MIDDLE
NAME NAME

SURNAME SURNAME

CURRENT CURRENT
ADDRESS ADDRESS
CONTACT CONTACT
NUMBER NUMBER
STATION STATION

SECTION SECTION

POSITION POSITION

HEALTH SURVEY HEALTH SURVEY


YES NO YES NO
1. Have you experienced for the last 14 days: 1. Have you experienced for the last 14 days:
Cough Cough
Colds Colds
Fever Fever
Sore Throat Sore Throat
Other sign and symptoms Other sign and symptoms

2. Current medical conditions (Eg. Diabetes, HPN, etc) 2. Current medical conditions (Eg. Diabetes, HPN, etc)

CLOSE CONTACT CLOSE CONTACT


YES NO YES NO

1. Have you provided or still providing care 1. Have you provided or still providing care
without personal protective equipment without personal protective equipment
(PPE) for COVID-19 patients? (PPE) for COVID-19 patients?

2. Have you traveled together in a close 2. Have you traveled together in a close
proximity (1 meter or less) with a COVID-19 proximity (1 meter or less) with a COVID-19
patient in any kind of transportation within patient in any kind of transportation within
14-day period after the onset of symptoms? 14-day period after the onset of symptoms?
3. Have you traveled together in a close 3. Have you traveled together in a close
proximity (1 meter or less) with a COVID-19 proximity (1 meter or less) with a COVID-19
patient in any kind of transportation within patient in any kind of transportation within
14-day period after the onset of symptoms? 14-day period after the onset of symptoms?

HISTORY OF COVID-19 HISTORY OF COVID-19


SUSPECT PROBABLE CONFIRMED NO SUSPECT PROBABLE CONFIRMED NO
1. Have you been 1. Have you been
considered as a considered as a
COVID-19 Suspect, COVID-19 Suspect,
Probable or Probable or
Confirmed in the last Confirmed in the last
14 days? 14 days?

TRAVEL HISTORY TRAVEL HISTORY


LIST THE PLACES YOU VISITED FOR THE LAST 14 DAYS LIST THE PLACES YOU VISITED FOR THE LAST 14 DAYS
DATE / TIME NAME / SIGNATURE DATE / TIME NAME / SIGNATURE

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