Self-assessment Form in Preparation for School Re-opening for Surveillance and Prevention of COVID-19
Please answer the survey truthfully for our school community’s safety.
Student Name
*
Contact Number
*
Year Level
*
Guardian who is filling this form
*
Father
Mother
Other
1. Did the student travel outside the country during the past 14 days? (If Yes, please specify the country name below
*
Yes
No
Country Name
2. Did the student travel within the country during the past 14 days? (If Yes, please specify the city / province name below)
*
Yes
No
City / Province Name
3. Has the family been under the 14-day quarantine?
*
Yes
No
4. Has the student been in contact with people that were infected, suspected or diagnosed with COVID-19 during the past 14 days?
*
Yes
No
5. Has the student been in contact with people coming from overseas during the past 14 days?(If Yes, please specify the country name below)
*
Yes
No
Country Name
6. Did the student have any of the following symptoms listed below during the past 14 days? Please select all symptoms that the student had
*
Fever
Cough
Runny Nose
Sore Throat
Shortness of Breath
Muscle Pain
Loss of Sense of Taste and Smell
None
7. Is the student living with elderly people (60 years old and above)?
*
Yes
No
8. Has the student been attending some activities (i.e. Tutoring Classes, Music classes, Swimming, etc.) during the past 14 days? (If Yes, please specify the activities below)
*
Yes
No
Activities
Remind and ask students to:
Wash their hands or use antiseptics
Not shake hands or contact physically
Wear face masks in the building
Submit
Should be Empty: