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School Name *

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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
Jeepney
Tricycle
Pedicab
Multicab
Habal-habal
Van
Other:

Is the school accessible through walking? *

Yes
No
If the barangay where the school is located has not recorded any confirmed COVID-19 case/s in
the past 28 days, and the school is accessible by public transportation or walkable, proceed in
answering this safety assessment tool, otherwise, your school cannot be nominated as a
participating school for the implementation of limited face-to-face learning modality.
The School Safety Assessment Tool (SSAT) shall be used to assess the readiness of the schools
to participate in the conduct of the pilot implementation of face-to-face learning modality in the time
of the COVID-19 pandemic. The data gathered shall be used as baseline information in
preparation for the safe reopening of classes.

For a school to be eligible for the implementation of the face-to-face learning delivery modality,
they need to meet all the indicators (YES to all indicators). In answering the SSAT, School Heads
shall ensure that key stakeholders are consulted. The Schools Division Office (SDO) shall facilitate
the administration of the tool to the nominated schools and shall create a composite team who will
conduct monitoring visits to validate the data and verify the results submitted by the schools.
A. MANAGING SCHOOL OPERATIONS
I. SHARED RESPONSIBILITY
1. The school has secured support of LGUs (Barangay, Municipality, City, Province) through a
resolution or a 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. *
Yes
No
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. *
Yes
No
II. ALTERNATIVE WORK ARRANGEMENT
1. The school has implemented an Alternative Work Arrangement necessary to deliver quality
basic education in a safe learning environment to learners. *
Yes
No
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 *
Yes
No
c. Teachers who physically report to not have comorbidities, immunodeficiency, or any health
risk/conditions *
Yes
No
d. Teachers who have service vehicles from and to area of residence and school *
Yes
No
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. *
Yes
No
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 *
Yes
No
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 *
Yes
No
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 *
Yes
No
h. Availability of a sterilization box where outputs (e.g., quiz papers) submitted by the learners will
be placed for disinfection *
Yes
No
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 *
Yes
No
IV. SCHOOL TRAFFIC MANAGEMENT
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. *
Yes
No
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 *
Yes
No
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) *
Yes
No
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
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
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
B. 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 learningo Class B: One straight week of pure distance learningo 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
C. 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
D. HOME-SCHOOL COORDINATION
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
Vaccinated Teaching Personnel
Number of Fully Vaccinated Male 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
Vaccinated Non-Teaching Personnel
Number of Fully Vaccinated Male 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
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