Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IX, Zamboanga Peninsula
Division of Zamboanga Sibugay
KABASALAN SCIENCE AND TECHNOLOGY HIGH SCHOOL
F.L. Peña, Kabasalan Zamboanga Sibugay
HEALTH FORM
I, _____________________________, declare that my entire household was not considered a close
contact, suspect, probable, or confirmed COVID-19 case the past 14 days. Further, we do not experience
any symptoms related to COVID-19 such as:
a. Fever f. Fatigue/ Tiredness
b. Cough and colds g. Headache
c. Difficulty of breathing h. Loss of taste or smell
d. Sore throat i. Body pains
e. Diarrhea
I hereby certify that the information given is true, correct and complete. I understand that any falsified
response may have serious consequences. I understand that my personal information is protected by RA
10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the date of
accomplishment, following the National Archives of the Philippines protocol.
________________________________ __________________
Name and Signature Date
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IX, Zamboanga Peninsula
Division of Zamboanga Sibugay
KABASALAN SCIENCE AND TECHNOLOGY HIGH SCHOOL
F.L. Peña, Kabasalan Zamboanga Sibugay
HEALTH FORM
I, _____________________________, declare that my entire household was not considered a close
contact, suspect, probable, or confirmed COVID-19 case the past 14 days. Further, we do not experience
any symptoms related to COVID-19 such as:
a. Fever f. Fatigue/ Tiredness
b. Cough and colds g. Headache
c. Difficulty of breathing h. Loss of taste or smell
d. Sore throat i. Body pains
e. Diarrhea
I hereby certify that the information given is true, correct and complete. I understand that any falsified
response may have serious consequences. I understand that my personal information is protected by RA
10173 or the Data Privacy Act of 2012 and that this form will be destroyed after 20 days from the date of
accomplishment, following the National Archives of the Philippines protocol.
________________________________ __________________
Name and Signature Date
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IX, Zamboanga Peninsula
Division of Zamboanga Sibugay
KABASALAN SCIENCE AND TECHNOLOGY HIGH SCHOOL
F.L. Peña, Kabasalan Zamboanga Sibugay
PARENT’S CONSENT FORM ON THE EXPANSION OF THE IMPLEMENTATION OF LIMITED
FACE-TO-FACE CLASSES
The Kabasalan Science And Technology High School recently underwent a location risk assessment and
school safety assessment, and has received approval from the Department of Education and
Department of Health to conduct face-to-face classes. This affirms that our school is compliant with the
minimum public health standards set by the government.
In light of this, the Kabasalan Science And Technology High School will participate in the pilot
implementation of face-to-face classes. This activity aims to further develop strategies, understand key
considerations of stakeholders, and identify resources required for the effective and efficient transition
of learners from distance learning to expanded face-to-face classes.
This activity will be conducted for a maximum of two months in schools that were carefully selected to
be in areas classified as minimal risk from COVID-19 and can offer diverse perspectives based on their
local context and best practices.
DURATION
The pilot face-to-face classes will be held from March 28, 2022 to ______every Monday,
Tuesday,Wednesday, Tursday from 7:30 to 11:45.
BENEFITS
This activity will address difficulties of learners in learning independently through pure distance learning
and lack of access to technology and household resources. Moreover, our learners will benefit in the
future from the information from this activity.
CONFIDENTIALITY
Any information that will be given during the activity will be kept strictly confidential, and personal
information will be treated in accordance with the Data Privacy Act of 2012. Be assured that information
about you or your child will not be shared outside of the implementation team. The participant’s name
will not be used when data from this activity will be analyzed.
VOLUNTARY PARTICIPATION
Participation in this activity is voluntary. You or your child may decline to participate or to withdraw
from participation at any time for any reason. Declining or withdrawal of participation will not result to
any penalty, or loss of benefits or reduction of any basic right to which your child is entitled. If you or
your child decide to withdraw participation, kindly inform the teacher adviser of your child.
EXCLUSION (LIMITATIONS/INELIGIBILITY)
In accordance with the health and safety protocols, children with existing comorbidities should NOT
participate in the Pilot Implementation of Limited Face-to-Face Learning Modality. Children who tested
positive of COVID-19 or who have household members who tested positive of COVID-19 shall follow the
required quarantine period consistent with the latest national guidelines on Return to School / Work
Policies and as provided in Section 7.4.6 Strategy to Reintegrate of the Guidelines and must be cleared
by a licensed medical doctor before they may participate. The same applies to children who tested
positive during the actual implementation. Parents/guardians shall sign a health form at the beginning
of each school term confirming that their child and/or any member of their household is not considered
as a close contact, suspect, probable, or confirmed COVID-19 case in the past fourteen (14) days, and
does not experience any symptoms related to COVID-19 such as, but not limited to, fever or chills,
cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, loss of taste
or smell, sore throat, congestion or runny nose, nausea, vomiting, and diarrhea before being permitted
to participate in the limited face-to-face classes.
RISKS, CONSENT AND WAIVER
As the parent or legal guardian of ______________________, I hereby acknowledge that I have been
informed of the details of the conduct of Pilot Implementation of Face-to-Face Learning Modality.
I understand that Kabasalan Science and Technology High School shall implement the minimum public
health standards set by the government to minimize risk of the spread of COVID-19, but it cannot
guarantee that my child will not become infected with COVID-19, given that COVID-19 is highly
contagious.
I understand that my child/ren’s in-person attendance in school will include associating with teachers,
fellow learners and school personnel, and other persons inside and outside of the school that may put
my child at risk of COVID-19 transmission, notwithstanding the precautions undertaken by the school.
I acknowledge that my child/ren’s participation in this activity is completely voluntary. While there
remains the risk of possible COVID19 transmission to my child/ren, and to the members of my
household, I freely assume the said risk and I permit my child/ren to attend school under this activity.
I am aware that symptoms of COVID-19 include, but are not limited to, fever or chills, cough, shortness
of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell,
sore throat, congestion or runny nose, nausea, vomiting, and diarrhea.
I confirm that my child/ren currently has none of those symptoms, and is in good health. I will not allow
my child/ren to physically go to school to attend classes if my child/ren or any member of my household
develops any of the said symptoms or any other symptoms of illness that may or may not be related to
COVID-19. I will also inform the school and not allow my child/ren to attend face-to-face classes if my
child/ren or any of my household members tests positive for COVID-19. My child/ren and I, with my
household members, will follow the required health and safety protocols and procedures adopted by
the school and our community.
To the extent allowed by law and rules, I hereby agree to waive, release, and discharge any and all
claims, causes of action, damages, and rights against the school and its personnel as well as officials and
personnel of the Department of Education relative to the conduct of the activity.
With full understanding, I – on behalf of myself, my household members, and my child/ren – hereby
freely and voluntarily give my consent to my child/ren’s participation in the activity from March 28, 2022
to June 24, 2022. I also attest that I had sought the views of my child/ren and he/she has expressed
willingness to participate in the activity.
CONTACT DETAILS FOR QUESTIONS OR PROBLEMS
For any concern or clarification, you may contact Policy Research and Development Division-Planning
Service through email address [email protected].
Signature of Parent / Guardian over Printed Contact Details:
Name:
Name of Child/ren: Date:
