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Department of Education: Deped Region 7 Covid-19 Assessment Form (Decaf)

This document is a COVID-19 assessment form used by the Department of Education in Region 7 of the Philippines. The form collects personal information about an individual such as name, age, symptoms, travel history, and exposure history. It is then used by health facilities to conduct a physical examination, note any pertinent medical history, and make recommendations on whether the individual is fit to study/work or requires further monitoring, investigation, or laboratory testing due to COVID-19.

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Goldie Paraz
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68 views2 pages

Department of Education: Deped Region 7 Covid-19 Assessment Form (Decaf)

This document is a COVID-19 assessment form used by the Department of Education in Region 7 of the Philippines. The form collects personal information about an individual such as name, age, symptoms, travel history, and exposure history. It is then used by health facilities to conduct a physical examination, note any pertinent medical history, and make recommendations on whether the individual is fit to study/work or requires further monitoring, investigation, or laboratory testing due to COVID-19.

Uploaded by

Goldie Paraz
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
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Republic of the Philippines

Department of Education

DepEd Region 7 COVID-19 Assessment Form (DECAF)

Name:______________________________________________ Age/Sex: ________ Date:____________


Division: ________ School: ___________________ Grade Level/Position:_________________
Parent/Guardian:________________________________ Contact Number:_____________________
Complete Home Address: ______________________________________________________________
Travel History: Departure Date:______ Arrival Date:_______ Destination:________________
Flight No.: _____________________
Port of Entry/Pier Name:__________
Symptoms (Please check appropriately):
fever/hilanat headache/sakit sa ulo stomachache
cough/ubo dizziness/lipong nausea/kasukaon
colds/sip-on tiredness/kapoy vomiting/nagsuka
difficulty of breathing/hangak muscle pain diarrhea/kalibanga
others:__________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
To be filled up by the Health Facility:
Physical Examination:
BP:_________mmHg Temp:__________⁰C HR:__________bpm RR:__________cpm
Skin: ____________________________ Abdomen: _________________________
HEENT: ____________________________ GUT: _________________________
C/L: ____________________________ Ext: _________________________
CVS: ____________________________ Others: _________________________

Pertinent History: (Write +/- accordingly):


FEVER ≥38⁰C COUGH/COLDS Travel History Exposure History

History of Travel/Exposure:
travel to or residence in a country/area reporting local transmission or area under
under enhanced communitry quarantine
close contact with a confirmed COVID-19 case
staying in the same close environment (workplace classroom, household, gatherings)
providing direct care without proper PPE to confirmed COVID-19 patient

Recommendation:
Unfit to study/work Person Under Investigation (Admission)
Person Under Investigation (Home Q.)
Person Under Monitoring (Home Q.)

For laboratory work-up:____________________________________________________


Fit to study/work Without Restrictions
With Restrictions:
*The information I have given is true, correct and complete. I understand that failure to answer any question may have serious
consequences (Article 171 and 172 of the Revised Penal Code of the Philippines).

______________________________________ _______________________________
Learner's/Parent's/Guardian's/Worker's Medical Officer's Name and Signature
Name and Signature License No.________
Date:____________ Date:_____________
DECAF)

_______________

_ _ _ _ _

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