School Safety Assessment Tool for Face-

to-Face Learning Modality

Readiness Assessment of Schools for the Opening of Face-to-Face Classes SY 2022-2023
 
[email protected] (not shared) Switch account
 
* Required

District *
Choose

Name of School *

Your answer

School ID *

Your answer

Respondent's Given Name/Middle Initial/Last Name *

Your answer

Position *

Your answer

Contact Number *

Your answer

DepEd Email Address *

Your answer
For the past twenty-eight (28) days, has the barangay where your school is located
recorded any confirmed COVID-19 case/s? *Kindly refer to your respective barangay
for the data. *
YES
NO

Is the school accessible through public transportation? *

YES
NO

If YES, what specific mode of transportation *

Pedicab
Van
Jeepney
Habal-habal
Others: specify
Multicab

Is the school accessible through walking? *

NO
YES

MANAGING SCHOOL OPERATIONS I. Shared Responsibility

Choose the most appropriate answer

1. The school has secured support of LGU's (Barangay Municipality, City, Province)
through a resolution or letter of support. *
YES
NO

2. The school has secured written consent from parents/guardians who will participate
in the limited face-to-face classes. *
YES
NO

3. The school has mobilized resources and support from community stakeholders to
meet the standards of the health and safety protocols. *
NO
YES

4. The school has conducted simulation activities among school personnel regarding
protocols and routines to replicate and discuss possible scenarios during the actual
conduct of face-to-face classes. *
NO
YES

II. Alternative Work Arrangement

Choose the most appropriate answer

1. The school has implemented an Alternative Work Arrangement necessary to deliver

quality basic education in a safe learning environment to learners. *
NO
YES

a. Number of teachers who physically report meets the required teacher: learner
ratio *
YES
NO

b. Teachers who physically report are 65 years old and below *

NO
YES

c. Teachers who physically report to not have comorbidities, immunodeficiency, or any

health risk/conditions *
NO
YES

d. Teachers who have service vehicles from and to area of residence and school *
NO
YES

e. Teachers who physically report are from within the city/municipality where
school/learning center is located *
YES
NO

2. The school has oriented teaching personnel and non-teaching personnel on the
Alternative Work Arrangement that will be implemented during the limited face-to-face
classes. *
NO
YES

III. Classroom Layout and Structure

1. The school has established mechanisms inside the classroom to ensure zero to
minimal risk of COVID-19 transmission of the learners. *
YES
NO

a. Number of seats to be occupied must not exceed from the required number of
maximum learners in the classroom *
NO
YES

b. Seats to be occupied must be at least 1-2 meters apart *

YES
NO

c. Numbers of seats shall be equivalent to the number of learners present *

NO
YES

d. Presence of markers and stickers on the floor to manage traffic system and physical
distancing inside the classroom *
YES
NO

e. Availability of working electric fans *

YES
NO

f. Open windows and doors at all times *

YES
NO

g. Installation of appropriate ventilation equipment such as general and exhaust

ventilation and CO2 monitoring devices *
NO
YES

h. Availability of a sterilization box where outputs (e.g., quiz papers) submitted by the
learners will be placed for disinfection *
NO
YES
i. Usage of high-efficiency particulate air (HEPA) filtration air purifiers to clean
recirculated air for air-conditioned spaces, provided that the unit is adequate for the
size of the room in which it is installed *
NO
YES

IV. School Traffic Management

Please click the appropriate response to each question

1. The school has set-up clear and easy-to-understand signages, preferably in local
languages and Braille, and mechanisms to strengthen observance of health protocols
and protective measures. *
NO
YES

a. Display of school map at the entrance point indicating the location of the
classrooms *
YES
NO

b. Designation of separate entrance and exit points in the school *

NO
YES

c. Designation of separate entrance and exit points in high traffic areas (unidirectional
markers, installation of signages for cueing and unidirectional movement, sectioning,
and queueing) *
NO
YES

d. Designated entrance and exit points in the classrooms *

YES
NO

e. Hallway ground markings for walking direction guide *

YES
No

f. Designation of areas for queue (e.g., restroom, library, principal's office, etc.) *
YES
No

V. Protective Measures, Hygiene Practices, and Safety Procedures

Please click the appropriate response to each question

1. The school has established safe entrance and exit procedures for teachers,
students, non-teaching personnel, and school visitors. *
YES
No

a. Availability of temperature thermal scanner or thermal gun in entrance and/or exit

gates *
YES
No

b. Availability of hand sanitizer or alcohol dispenser in school gates *

YES
No

c. Availability of surgical masks at school entrance reserved for symptomatic

individuals *
YES
No

2. The school has established a contact tracing procedures/tools for school-goers. *

YES
No

a. Health declaration sheet for school personnel *

YES
No

b. Health declaration sheet for students *

YES
No

c. Contact tracing tool for school-goers *

YES
No

3. The school has mobilized the School COVID-19 DRRM team that will take charge in
ensuring effective implementation of the school’s health and safety protocols that are
in place and are observed during the preparation and implementation of limited face-
to-face classes. *
YES
No
a. Designation of a Safety Officer who shall serve as the focal person for the health
and safety protocols of the school *
YES
No

4. The school has set up a proper sanitation and hygiene facility for school-goers. *
YES
No

a. Availability of handwashing station with clean and safe water supply *

YES
No

b. Availability of clean and safe toilet facilities *

YES
No

c. Schedule of supervised handwashing and toothbrushing activities *

YES
No

d. Placement of handwashing facilities in a strategic location (e.g., school entrance) *

YES
No

e. Placement of trash bins in strategic locations *

YES
No

f. Visuals signages on proper waste management practices near trash bins *

YES
No

5. The school has ensured regular sanitation and disinfection of school facilities,
furniture, and equipment. *
YES
No

a. Schedule of sanitation of frequently touched surfaces (e.g., table, doorknobs, light

switches, etc.) every after end of a school shift *
YES
No
b. Schedule of disinfection of school facilities (e.g., chairs, desk, blackboard, toilet
facilities) *
YES
No

c. Availability of sanitation and disinfecting materials *

YES
No

6. The school has ensured a proper disposal system of infectious wastes, such as
used tissues and masks, in non-contact receptacles.
YES
No

a. Disposal of all used PPEs in a separate leak-proof yellow trash bag/container with a
cover properly labeled as “USED PPE” *
YES
No

b. Collection of the leak-proof yellow trash bag/container regularly or twice a day (after
end of class and after working day) from designated/specific area to the general
collection area for treatment and disposal *
YES
No

c. Availability of medical-grade face mask required for school personnel when

collecting/handling the leak-proof yellow trash bag/container *
YES
No

d. Treatment through disinfection or spraying of the collected wastes with a chlorine

solution (1:10) in accordance with DOH Department Memorandum No. 2020-0157
“Guidelines on Cleaning and Disinfection in Various Settings as an Infection
Prevention and Control Measure Against COVID-19” *
YES
No

e. Disposal of the disinfected PPE with general waste to the final disposal facility  *
YES
No
VI. Communication Strategy
1. The school has developed a communication plan. *
YES
No

a. Identification of platform of communication for coordination purposes

among the learners, parents/guardians, and teachers *
YES
No

b. Database of contact details including contact number and address of

parents/guardians of the learners are kept to inform them in case their child
shows flu-like symptoms while in school premises *
YES
No

c. Development of child-friendly Information, Education and Communication

(IEC) materials on hygiene practices and respiratory etiquette including hand
hygiene (hand disinfection thru handwashing and/or use of 70% isopropyl
alcohol), respiratory hygiene and cough etiquette (coughing or sneezing into
tissues or one’s elbow), protective measures (proper use of face shield and
face mask, physical distancing), among others, that are posted in common
areas and are available in local languages and braille. *
YES
No

2. The school has prepared an orientation session for learners, parents, guardians,
teaching and non-teaching personnel, external stakeholders, and LGU of the eligibility
criteria for participation, existing protocols, mechanisms, and procedures needed in
the conduct of the limited face-to-face classes. *
YES
No

a. Schedule of the orientation (at least one week prior to the conduct of the
face-to-face classes) *
YES
No
 b. Orientation materials are made available for distribution to teachers,
learners, parents, BLGU, DRRM team members, and persons-in-charge in
ensuring observance of protocols, mechanisms, and procedures *
YES
No

3. The school has a proactive COVID-19 local hotline/help desk or any similar local
mechanism that connects and coordinates to the hospitals, testing facilities, and
LGUs. *
YES
No

4. The school has prepared a re-orientation session for school stakeholders on

measures needed for the reopening of the school in the event of resurgences and
school lockdown. *
YES
No

VII. Contingency Plan

1. The school has followed a decision model and contingency plan for reclosing
and reopening the school in case of COVID-19 resurgence in the community. *
YES
No

1. The school has followed a decision model and contingency plan for
reclosing and reopening the school in case of COVID-19 resurgence in the
community. *
YES
No

a. Inclusion of decision points for school lockdown dependent on the

assessment and decision of the Local Task Force against COVID-19 (LTF) with
the following considerations:

○ When there is suspected, probable, or confirmed COVID-19 case to

facilitate disinfection and contact tracing;

○ Change in number of community transmission and quarantine risk

classification identified by IATF;
 ○ Violations/instances of non-compliance of learners or personnel with the
minimum public health standards or PDITR for review of protocols *
YES
No

b. In the event of school lockdown, all learners shall revert to distance

learning. *
YES
No

c. Implementation of a 24-hour granular lockdown period for disinfection

following identification/detection of suspect, probable, or confirmed COVID-19
confirmed case/s, only after which can it be opened for use to occupants. *
YES
No

d. Consideration of the following for the reopening of classes after a school

lockdown: o Completed contact tracing

o Completed disinfection activities

o 14 days without confirmed cases in the school

o School is in a barangay with low to no community transmission

o Area where the school is located is classified as minimal-risk *

YES
No

e. Implementation of return to school/work policies consistent with latest

national guidelines

o For close contacts:

i. For fully vaccinated individuals: Seven (7)-day quarantine has been completed
regardless of negative test result
ii. For unvaccinated or with incomplete vaccination: Fourteen (14)-day
quarantine has been completed regardless of negative test result

o For suspect, probable or confirmed cases, whether fully vaccinated,

unvaccinated, or with incomplete vaccination:
 i. For asymptomatic: Ten (10)-day isolation have passed from the first viral
diagnostic test and remained asymptomatic throughout their infection
ii. For mild to moderate COVID-19 confirmed cases: Ten (10)-day isolation
have passed from onset of the first symptom, respiratory symptoms have
improved (cough, shortness of breath), AND have been afebrile for at least
24 hours without use of antipyretic medications.
iii. For severe and critical COVID-19 confirmed cases: Twenty-one (21)-day
isolation has passed from onset of the first symptom, respiratory symptoms
have improved (cough, shortness of breath) AND have been afebrile for at
least 24 hours without the use of antipyretic medications.
iv. For immunocompromised, do RT-PCR testing on the 10th day. If RT-PCR
test results turn out positive, refer to Infectious Disease Specialist. If RT-
PCR test results turn out negative, discharge from isolation. o Medical
certification or repeat testing is not necessary for the safe return to work of
immunocompetent individuals, provided that a licensed medical doctor
certifies or clears the patient. *
YES
No

2. The school has developed strategies for the continuity of learning while the
school is closed until the local authorities have determined the safe resumption of
face-to-face classes. *
YES
No

a. Distance learning modalities during lockdown in the decision model

and contingency plan *
YES
No

b. Strategies for the reopening of schools after the lockdown in the

decision model and contingency plan *
YES
No

FOCUSING ON TEACHING AND LEARNING I. Learning Resources

1. The school has secured sufficient supply of learning resources needed for the face-
to-face classes. *
YES
No

a. Implementation of 1:1 Student to Self-Learning Module (SLM) to lessen student

interaction during class hours *
YES
No

b. Implementation of 1:1 Student to Textbook ratio to lessen student interaction during

class hours *
YES
No

II. Limited Face-to-Face Classes

1. The school has designed class program/s that cater both learners of the limited
face-to-face classes arrangement and distance education while observing the
maximum 6-hour classroom teaching hours of teachers. *
YES
No

a. Arrangement of the number of class sections in a way that each class section will
be able to attend face-to-face classes: o Class A: Half-day face-to-face classes in one
straight week and other half-day for distance learning o Class B: One straight week of
pure distance learning o Classes shall alternately attend face-to-face classes every
week for the whole duration of the pilot implementation *
YES
No

b. Class program indicating specific schedule/breakdown of hours for the face-to-face

classes including staggered start and close of the school day per grade level *
YES
No

c. Class program indicating specific schedule/breakdown of hours for distance

learners including staggered start and close of the school day per grade level *
YES
No

d. Class program indicating schedule of staggered break time hours

YES
No
e. Signages on protocols prohibiting activities that require large gatherings *
YES
No

f. Implementation of the maximum hours of stay of the learners in schools (4.5 hours
for G1-6 learners and 3 hours for kindergarten learners) *
YES
No

2. The school has comprehensively profiled learners who will participate in the
implementation of the face-to-face classes. *
YES
No

a. Learners who reside within the city/municipality where the school/learning center is
located *
YES
No

b. Learners who can walk their way to school, or ride with available private transport,
or with regulated public transportation *
YES
No

c. Learners without existing comorbidities *

YES
No

d. Prioritization of learners who require childcare, such as those whose parents must
work outside the home, or who have no directly available and immediately responsible
adults/guardians at home *
YES
No

e. Prioritization of learners who are heavily dependent on face-to-face learning

interventions, such as Key Stage 1 learners (Kindergarten to Grade 3) *
YES
No

f. Prioritization of learners who struggle to meet required learning competencies *

YES
No
g. Prioritization of Senior High School (SHS) learners enrolled in Technical-Vocational-
Livelihood (TVL) track requiring workshop equipment in school *
YES
No

h. Prioritization of learners that are documented to be affected by mental health

concerns that may be eased by face-to-face interactions *
YES
No

3. The school has ensured an attendance monitoring of learners to determine which

participating learners are exhibiting difficulties in coming to school and which learners
who cannot participate in face-to-face classes will revert to full distance learning. *
YES
No

4. The school has informed teachers to conduct consultations with parents, provision
of feedback and instructional support for learners, facilitation of assessment,
preparation of Weekly Home Learning Plan (WHLP), and other related tasks after
face-to-face classes. *
YES
No

5. The school has ensured prohibition of conduct of physical or face-to-face large

gatherings, group work, or activities that will require close contact or where physical
distancing may not be possible (e.g., school activities, field trips, sports festivals, flag
ceremonies). *
YES
No

III. Teacher Support

1. The school has provided an appropriate learning and development support plan in
providing better quality basic education services. *
YES
No

a. Learning and Action Cells (LAC) sessions highlighting provision of

remediation/intervention for learners during the face-to-face classes *
YES
No
b. Coaching, mentoring, and training relevant in facilitating blended learning
approach *
YES
No

2. The school has oriented teachers on their budget of work and ensured that the
school requirement for the learners is in observance of academic ease. *
YES
No

a. Orientation on the implementation of the Most Essential Learning Competencies

(MELCs) included in their budget of work during the limited face-to-face classes *
YES
No

b. Orientation on the observance of academic ease and provision of flexibility to

learners in managing limited face-to-face classes *
YES
No

WELL BEING AND PROTECTION I. Personal Protective Equipment

1. The school has secured sufficient supply of personal protective equipment (PPEs)
for learners and school personnel. *
YES
No

a. 1:1 Face mask to Person (daily) ratio *

YES
No

b. 1:1 Face shield to Person ratio *

YES
No

c. 1:1 Toothbrush and Toothpaste to Learner ratio (K-6 learners) *

YES
No

d. 1:1 Bar of soap to Learner ratio enough for 5x of handwashing per day (K-6
learners) *
YES
No
e. Availability of emergency health kits that include PPEs and other needed supplies
and materials in the school clinic *
YES
No

f. Availability of PPEs for COVID-19 team members, health personnel, and

maintenance, and security guards *
YES
No

2. The school has secured adequate supply of face masks, face shields, and/or other
COVID-19 protective gears for learners. *
YES
No

a. 1:1 Replacement of lost and damaged PPE to Person ratio *

YES
No

3. The school has ensured that the available sanitation and disinfection materials are
approved by the Philippine Food and Drug Administration (FDA) such as: *
YES
No

a. Sodium hypochlorite recommended ratio of 0.1% (1000 ppm) by dissolving ½ tsp of

chlorine or 2 g to 2L of clean water for regular disinfection, and recommended ratio of
0.5% (5000 ppm) for body fluids by dissolving 1 tbsp of chlorine or 10 g to 2L of clean
water *
YES
No

b. Ethanol in all surfaces at a recommended ratio of 70-90%, or *

YES
No

c. Hydrogen peroxide in all surfaces at a recommended ratio of >0.5% *

YES
No

4. The school has secured sufficient supply of sanitation and disinfection materials for
strategic school locations. *
YES
No

a. 1:1 bottle of hand-sanitizers/alcohol-based solutions/other disinfectants to

restroom *
YES
No

b. 1:1 bottle of hand-sanitizers/alcohol-based solutions/other disinfectants to

classroom *
YES
No

c. 1:1 bottle of hand-sanitizers/alcohol-based solutions/other disinfectants to

entrance/exit point *
YES
No

5. The school has ensured PPE requirements, specifications, and standards for
different types of COVID-19 management activities in accordance with DOH DM 2020-
0176A. *
YES
No

a. Availability of medical mask and face shields for triage and screening of individuals
in points of entry (for personnel in school entrances *
YES
No

b. Availability of medical mask, goggles or face shield, gloves, gown for caring for a
suspected case of COVID-19 with no aerosol-generating procedure (for personnel in
school clinics) *
YES
No

c. Availability of respirator (N95 or FFP2), goggles or face shield, gloves, gown for
caring for suspected/confirmed cases of COVID-19 with no aerosol-generating
procedure for personnel in school clinics) *
YES
No

d. Availability of full PPE for assisting in transporting passengers to a healthcare

facility *
YES
No

II. COVID-19 Case Management

1. The school has developed strategies to prevent COVID-19. *
YES
No

a. Conduct of hand hygiene and temperature checks using a thermal scanner prior to
entering the school *
YES
No

b. Prioritization of non-face-to-face communications and coordination through

available platforms and discouragement of entrance of school visitors and other
external stakeholders *
YES
No

c. Conduct of daily rapid health checks in the classroom *

YES
No

d. Conduct of necessary disinfection activities especially in the areas of the school

frequented by personnel or learners that tested positive *
YES
No

e. Availability of surgical face masks and school clinic for further assessment of
anyone who will show symptoms of COVID-19 *
YES
No

f. Establishment/setting-up/refurbishment of a school clinic to provide basic health

services to all school-goers, such as: o Health assessment and physical examination,
as needed o Appropriate intervention, first aid, or treatment o Proper management of
symptoms, including rest at home o Referral and follow-up of learners, teachers, and
personnel to appropriate facilities *
YES
No
g. Designation of private screening area at the entrance where school-goers who
show symptoms upon screening can be further examined, or referred *
YES
No

h. Designation of separate space where sick school-goers who have been managed in
the clinic can temporarily stay, awaiting referral to the appropriate health facility,
without creating stigma *
YES
No

i. Designation of clinic teachers(s) in absence of school health personnel, who shall

provide basic health services and facilitate referral in coordination with the school
health personnel at SDO, in absence of school-based health personnel *
YES
No

j. Orientation to the clinic teacher by the school health personnel at the SDO for proper
guidance on how to effectively run the school clinic *
YES
No

k. Reiteration of protocols for learners, teachers, and personnel who manifest COVID-
19 symptoms to not physically report to school and seek medical advice virtually if
possible *
YES
No

l. Record of students’ health status and development, including immunization checks

to prevent outbreak-prone vaccine-preventable disease (e.g., measles *
YES
No

2. The school has identified strategies to detect COVID-19. *

YES
No

a. Cooperation with the local health authorities in the tracing and quarantine of close
contacts of confirmed cases of COVID-19 consistent with DOH guidelines *
YES
No
b. Presence of the School DRRM Team who shall ensure that contact tracing
activities, as required by the local health authorities, are initiated, and completed
among the possible close contacts among DepEd personnel and learners *
YES
No

c. Close coordination with Epidemiology Surveillance Unit (ESU) officers per setting o
DOH Regional ESU of reporting school o LGU City ESU/Provincial ESU/Municipal
ESU of reporting school o DOH Regional ESU of identified case (place of residence) o
LGU City ESU/Provincial ESU/Municipal ESU of identified case (place of residence) *
YES
No

d. Development of a reporting system requiring parents to report to the school if their

children are experiencing flu-like system, recommendation of testing to be done
immediately with support and guidance from the LGUs *
YES
No

e. Provision of health form to parents/guardians at the beginning of each school term

confirming their child and/or family members do not have COVID-19 before being
permitted to go to school to be submitted 24 to 72 hours prior to the start of school
opening *
YES
No

3. The school has developed strategies to isolate and treat COVID-19. *

YES
No

a. Designation of rooms for isolation of students and personnel with fever and flu-like
symptoms near the entrances *
YES
No

b. Availability of transport vehicles from school to Temporary Treatment and

Monitoring Facility (TTMF) *
YES
No
c. Notification of family member/guardians of the learner, or family member of school
personnel who show flu-like symptoms *
YES
No

d. Immediate isolation and referral of the personnel/s or learner/s who show COVID-
19 symptoms based on the severity for proper management and appropriate testing *
YES
No

e. Provision of necessary emergency care to the personnel or learner following

precautionary measures, by the health personnel or designated clinic teacher *
YES
No

f. Referral/full disclosure of the case to the identified health authority (e.g., barangay
health station, rural health unit) for further evaluation or referral to a hospital if
needed *
YES
No

g. Strict observance of advice from health authorities including possibility of home

quarantine or isolation in a quarantine facility or confinement *
YES
No

h. Report of the close follow-up of the attending/assigned school health personnel or

designated clinic teacher with the condition of the identified learner/personnel to the
SDO School health and Nutrition Unit/Section, as required by existing reporting
mechanisms *
YES
No

i. Strict compliance of learners and personnel who have tested positive for COVID-19
to not return to school without clearance from medical authorities *
YES
No

j. Monitoring and provision of necessary support of the School Head (SH) to all cases
(close contacts, suspect, probable, confirmed) *
YES
No

k. Coordination of SH to all cases with DepEd school health personnel and local
health authorities *
YES
No

l. Coordination of SH with the SDO in ensuring continuity of teaching and learning in

line with the school’s contingency plan *
YES
No

m. Strict observance of provision of Section IV.A (Screening of Returning Personnel

and Learners and Testing Protocol) of the Specific Measures for COVID-19 Prevention
and Mitigation in Schools (Enclosure No. 2 to DepEd Order No. 014, s. 2020) before
the participation of COVID-19 infected learners or personnel in the face-to-face
classes *
YES
No

4. The school has developed strategies in providing psychosocial support to the

learners, teachers, and personnel. *
YES
No

a. Allotment of time and preparation of modules on Mental Health to be facilitated by

their respective classroom advisers or designated teachers *
YES
No

b. Designation of trained teachers who will facilitate activities fostering Mental Health
such as mental health topics, nature of COVID-19, and preventive measures (WASH,
physical distancing, etc.) *
YES
No

c. Setting up of an operational Guidance Office that is staffed by a registered guidance

counselor (RGC) or a designated guidance associate (not an RGC but is trained on
MHPSS and is capable of effective referral) every school day, to provide basic mental
health services to learners, teachers, and personnel who may need such services *
YES
No

d. Availability of a hotline/online platform in the SDOs to provide counseling services

to learners, teachers, and personnel who require counseling services, in absence of
an RGC *
YES
No

e. Provision of specialized psychosocial support to learners, teachers and personnel

who are confirmed to be positive, under isolation/ quarantine, and categorized as
suspect and probable, through the Guidance Office using the DRRMS MHPSS
materials as reference *
YES
No

f. Establishment and contextualization of the inter-sectoral referral pathways to ensure

that psychosocial needs of both the personnel and the learners are provided *
YES
No

g. Engagement of parents, guardians, or any care providers of learners on taking care

of mental health and creating a positive environment *
YES
No

h. Coordination of mechanisms to ensure that the mental health and the basic needs
of learners and personnel with pre-existing mental health conditions and special needs
including neurologic and substance abuse disorders such as medications and other
key services are provided *
YES
No

i. Strict adherence to Republic Act No.10173 or the Data Privacy Act of 2012 in the
provision of mental health services and referral *
YES
No

j. Promotion of “school-life balance” through proper scheduling of schoolwork that will

allow learners to enjoy quality time at home *
YES
No
k. Mobilization of trained Psychological First Aid (PFA) providers of the schools to
provide necessary mental health and psychosocial support to concerned personnel or
learners *
YES
No

5. The school has established a clear procedure of referral system for COVID-19
confirmed and suspected personnel and learners. *
YES
No

a. Communication plan which includes coordination system with LGU for school
personnel and learners who show flu-like symptoms *
YES
No

b. Communication plan which includes a referral system for COVID-19 confirmed and
suspected personnel and learners *
YES
No

c. Flow chart of the referral system *

YES
No

6. The school has established a clear contact tracing and quarantine system for close
contacts of COVID-19 confirmed positive cases. *
YES
No

a. Communication plan which includes coordination system with local health

authorities in contact tracing and quarantine of close contacts of confirmed COVID-19
positive cases *
YES
No

b. Communication plan which includes notification of family/parent(s)/guardian(s) of

the concerned learner/s *
YES
No

c. Flow chart of the contact tracing and quarantine system *

YES
No

d. Contingency plan for school lockdown *

YES
No

III. Including the Most Marginalized

1. The school has identified learners who are most vulnerable and disadvantaged in
terms of access to learning as indicated in the eligibility of learners, such as inclusion
of: *
YES
No

a. indigent children *
YES
No

b. out-of-school youth *
YES
No

c. physically and mentally handicapped *

YES
No

d. distressed individuals and families, including internally displaced persons (IDPs) *

YES
No

e. low resourced students *

YES
No

f. abandoned and neglected children *

YES
No

g. street children *
YES
No

h. children of former rebels *

YES
No

i. children living in conflict-affected areas and vulnerable communities (CVAS) *

YES
No

j. children with disabilities and SPED students *

YES
No

k. children from Geographically Isolated and Disadvantaged Areas *

YES
No

2. The school has identified learners who are most vulnerable and disadvantaged in
terms of access to learning as indicated in the eligibility of learners, such as inclusion
of: *
YES
No

a. Inclusion of learners who need assistive devices that do not require them to remove
their face masks *
YES
No

b. Coordination with partner agencies in the provision of assistive devices such as

wheelchairs, cane, walkers, and others *
YES
No

c. Ensured that parent/guardian of learners are informed that his/her child has their
own assistive device during face-to-face classes *
YES
No

3. The school has developed learning strategies to cater the needs of the
disadvantaged learners such as modules in braille, mother-tongue languages, and
usage of Filipino Sign Language. *
YES
No
4. The school has ensured participation in school-based services which includes but is
not limited to feeding and nutrition programs, immunizations, Mental Health and
Psychosocial Support (MHPSS), prevention of Violence against Children (VAC) (i.e.,
bullying from social stigma) and other health services. *
YES
No

5. The school has established close coordination with the Department of Social
Welfare and Development (DSWD) Case Managers of those learners who are
marginalized; Other partner agencies and organizations such as National Council on
Disability Affairs (NCDA). *
YES
No

6. The school has coordinated with their respective local government units with the
implementation of routine school-based immunization (SBI) and other school health-
related services such as but not limited to deworming and weekly iron-folate acid
supplementation (WIFA). *
YES
No

a. Routine implementation of SBI together with school health services among target
learners *
YES
No

b. Facilitation of the completion of routine immunizations through regular immunization

mechanisms available through the National Immunization Program (NIP) *
YES
No

c. Routine immunization card checks through the school nurse or the designated clinic
teachers to ensure that children entering schools have completed their routine
immunization (i.e., 3 doses of Polio and DPT-HepB-Hib vaccines, and two doses of
Measles-containing vaccines) in the community *
YES
No

d. Referral of learners who have not completed their routine infant vaccines to the
nearest LGU/private pediatrician for catch-up vaccination *
YES
No

e. Participation in intensive health promotion campaign activities/supportive-policies

that shall be instituted by schools in collaboration with their local health offices to
maintain optimal health-seeking behaviors of learners and other community
members *
YES
No

Home-School Coordination
Please click the appropriate response to each question

1. The school has developed a plan in coordinating with the Barangay Local
Government Unit (BLGU) or the Barangay Health Emergency Response Team
(BHERT) in ensuring that protocols are observed properly. *
YES
No

a. Operationalization of the Preventative Alert System in Schools (PASS) for COVID-

19 (per DepEd Memorandum No. 15, s. 2020) *
YES
No

2. The school has developed a strategy in orienting parents on health protocols and
safety measures. *
YES
No

a. Safe drop-off and pick-up procedures *

YES
No

b. Safety precautions and preventive measures while commuting [e.g., wearing of

proper face masks and face shields, refrain from talking and eating while in public
transportation, ensure adequate ventilation, frequent and proper disinfection,
appropriate physical distancing] *
YES
No

c. Safety precautions and preventive measure upon entering the school premises *
YES
No

3. The school has identified a designated waiting area with proper ventilation for
parents/guardians. *
YES
No

VACCINATION RECORD
Number of male Teaching Personnel *

Your answer

Number of Fully Vaccinated Male Teaching Personnel *

Your answer

Number of Female Teaching Personnel *

Your answer

Number of Fully Vaccinated Female Teaching Personnel *

Your answer

Number of Vaccinated (1st Dose Only) Male Teaching Personnel *

Your answer

Number of Vaccinated (1st Dose Only) Female Teaching Personnel *

Your answer

Number of Male Non-Teaching Personnel *

Your answer

Number of Fully Vaccinated Male Non-Teaching Personnel *

Your answer
Number of Female Non-Teaching Personnel *

Your answer

Number of Fully Vaccinated Female Non-Teaching Personnel *

Your answer

Number of Vaccinated (1st Dose Only) Male Non-Teaching Personnel *

Your answer

Number of Vaccinated (1st Dose Only) Female Non-Teaching Personnel *

Your answer