Page 1 of 5 TEMPLATE FOR QUICK TRIAGE FORM FOR RETURNING EMPLOYEES (APOR AND NON - APOR) POST - COMMUNITY QUARANTINE Form Number: ________ (indicate pre - assigned serial numbers) Name of Office/Agency: ____________________________ Date and Time of Arrival of Employee:___________________ Name of Employee: ___________________________ Temperature: ____ Division/Unit: ________________ Name of Triage Officer: _________________ A. CURRENT INFOR MATION: (Please ensure that all information is made available) Exposure History: 1. Where did you live in the past two weeks? Write complete address. (If the employee had resided in multiple areas, write complete address of all areas indicating the exact da tes of residence.) _______________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Is/Are this/these area/s included in the list of areas with confirmed COVID - 19 cases? (Triage officer refers to list provided by the Regional Epidemiology and Surveillance Unit or RESU.) ( ) Yes ( ) No 2. In the past two weeks, have you: Indicate “ √ ” if “YES” or “x” if “NO” 2.1 ( ) Provided direct care for a lab - confirmed COVID - 19 patient? 2.2 ( ) Worked together or stayed in the same close environment as a COVID - 19 patient? 2.3 ( ) Traveled together with a lab - confirmed COVID - 19 patient in any kind of veh icle or conveyance? 2.4 ( ) Lived in the same household as a lab - confirmed COVID - 19 patient? Page 2 of 5 B. SIGNS AND SYMPTOMS: Interview the employee for the presence of the following signs and symptoms: (If there are any “yes” responses, ask when the symptom st arted.) (1) Signs/Symptoms (There may be more than one) (2) Presence or absence of signs and symptoms (indicate “ √” for presence, or “x” for absence) (3) Date of onset of symptom/s (write “N/A” if “x” in Column 3) Sore/painful throat Colds or runny nose Cough Headache Fever (temperature above 37.6 °C ) Difficulty of breathing Other symptoms (i.e. headache, fatigue, body pains, diarrhea), if any: please indicate specific symptom in Column 2 and write corresponding date of onset in Column 3 Other symptoms (Pls. write down) Date of onset of each symptom Page 3 of 5 C. DECISION TABLE These decisions shall apply to ALL employees, whether APOR or non - APOR. Triage Officer shall check only one decision below and perform the corresponding action. (Reference: Department Memorandum No. 2020 - 0187, “Must - know COVID - 19 Issuances and Materials as of April 20, 2020) CONDITIONS (All conditions must be present) CLASSIFICATION ACTION ( - ) fever and cough or colds, ( - ) travel history to a place with local transmission, and ( - ) reside in area with COVID transmission, and ( - ) exposure to COVID - 19 case Not COVID - 19 √ Human Resource Division to allow employee to time in to report to work √ Daily self - monitoring or HRMD monitoring and documentation for fever, cough or colds (+) fever and cough or colds, ( - ) travel history and ( - ) exposure to COVID - 19 case Not COVID - 19 √ Human Resource Division to refer employee to a primary care provider of choice for appropriate management √ May report to work once cleared by a physician as “fit to work.” ( - ) fever and cough or colds, (+) travel history from a place with local transmission of COVID - 19 in the past 14 days, and/or, (+) resides in area with local transmission of COVID in the past 1 4 - days Person Under Monitoring √ Human Resource Division to conduct employee to their respective Barangay Hall for documentation and daily monitoring by the BHERT, and √ Employee to undergo 14 - day quarantine, at either, at home (if quarantine residence i s compliant to quarantine standards) or in a designated facility ( - ) fever and cough or colds, (+) prolonged, close contact with a confirmed case of COVID - 19 Close contact of COVID - 19 case √ Human Resource Division to refer employee immediately to PESU fo r contract tracing √ Employee to be quarantined and monitored for 14 days in a designated community quarantine Page 4 of 5 facility or at home, if quarantine residence is compliant to quarantine standards √ Employee should be brought immediately to Panopdopan District Hospital for confinement (+) fever and cough or colds, (+) travel history from a place with local transmission of COVID - 19 COVID - 19 Suspect √ Bring employee for immediate triage to the Panopdopan District Hospital or to the hospital of choice for triag e and appropriate management (Employee needs to be confined in hospital or in Temporary Treatment and Monitoring Facility) (+) fever and cough or colds, (+) close prolonged contact with a confirmed case of COVID - 19 Close contact of COVID - 19 case √ Immedi ately refer to Panopdopan District Hospital for confinement and/or referral D. CLASSIFICATION OF EMPLOYEE: Based on the classification in the Decision Table above, the employee is hereby classified as (write down the classification): ____________________________________________________________ E. ACTIONS TO BE DONE: ____________________________________________________________ ____________________________________________________________ NAME AND SIGNATURE OF RESPONSIBLE OFFICER ____________________________________ YOU HAVE REACHED THE END OF THE TRIAGE PROCESS. TO BE READ AND SIGNED BY THE EMPLOYEE: Page 5 of 5 DECLARATION: I hereby certify that the above information is true and complete. I understand that my failure to answer, or any fal se or misleading information is given by me may be used as a ground for the filing of cases against me under Articles 171 and 172 of the Revised Penal Code of the Philippines, or Republic Act No. 11332, otherwise known as the “Law on Reporting of Communic able Disease.” (Ako ay nagpapatunay na ang mga impormasyon na aking binigay ay totoo at kumpleto. Naiintindihan ko na kung anumang maling impormasyon ay maaring maging dahilan para sa paghain ng kasong kriminal laban sa akin sa ilalaim ng Articles 171 at 172 ng Revised Penal Code o sa ilalaim ng Republic Act No. 11332. ) ___________________________________ EMPLOYEE'S SIGNATURE OVER NAME (PANGALAN AT PIRMA) __________ DATE (PETSA)