Annex “A” Say ey Professional Regulation Commission INFORMED CONSENT ON THE POTENTIAL RISK ASSOCIATED WITH TAKING THE TEACHERS LICENSURE EXAMINATION (profession) PLEASE READ THIS DOCUMENT CAREFULLY. You are given this informed consent form because the Professional Regulation Commission (PRC) and Professional Regulatory Board of ER HERS encourage your participation in the. TEACHERS. licensure examination, All known precautions are taken to safeguard all examinees, but the PRC/PRB cannot, ‘guarantee your absolute safety from any potential source of infection. You are asked to sign this form to signify your consent to participate in the said activity despite the potential risks. INFORMATION SHEET Introduction and Purpose of the Activity On March 11, 2020, the World Health Organization (WHO) has declared COVID-19 a pandemic with confirmed cases nearing twenty million (20,000,000) around the world without yet any sign of decline. The Philippines was no exception. With the continuing upsurge of recorded cases per day, the country needs to reinforce the number of its health workers to fight this pandemic. Following the request of different professional organization and other stakeholders, the Commission is prepared, although with greater precaution this time, to discharge its mandate of conducting the licensure examinations. Procedure The PRC are instituting health safety protocols to ensure the safety of all examinees, as well as the PRC personnel involved in the conduct of the examination. Listed below are the established best practices and their respective percentages of risk reduction of COVID-19 transmission: + 95% if you use N95 mask, 76% for surgical mask + 67% if you wear face shield+ 90% if there is distance of 1 meter, 92% if 2 meters (For a more detailed information, please refer to PRC Memorandum Order No. s. 2020 entitled “STRICT HEALTH PROTOCOLS TO BE OBSERVED IN THE CONDUCT OF LICENSURE EXAMINATIONS DURING THE COVID-19 PANDEMIC’). Risks By participating in the examination, it is possible that you will be exposed to COVID- 19. There is, for example, a chance that you might contract the virus while transporting to the venue. Although reduced in number with the mandatory minimum distances between examinees, you will still be staying in an enclosed room together with other examinees for several hours. Nonetheless, we assure you that the PRC will implement all known safety measures prescribed by the Omnibus Guidelines of the Inter-Agency Task Force (ATF) and the recommendations of the scientific community to reduce the possibility of infection. You still have the responsibility to weigh the risks against the benefits. Your judgment and discernment will guide you in deciding whether to take the licensure examination or not. Alternative to Participating in the licensure examination As a rule, all examinees who fail to take the licensure examination will be considered absent and need to be re-apply and pay for the next exam. By way of exemption, if you fail to participate in the examination because of health reasons, travel restrictions or any other valid reasons, please inform the concerned Regional Office of your place of examination within the week prior to the exam. You will be allowed to take the next scheduled licensure examination, provided that the requirements mentioned herein are complied with. Post Examination Requirement Fifteen (15) days, after the examination, we require the examinees to submit a post- exam health status update (Annex C) to help the examinees and future conduct of licensure examinations. The form can be downloaded from the website (www.pre.gov.ph) and this can be sent through the official email address of the Regional Office where you take your licensure examination. Please provide the information as accurately as possible. Agreement to Participate: If you agree to participate in the licensure examination, please indicate so by signing on the specified space below. Thank you.CERTIFICATE OF CONSENT 1, PANGI® , MELODY Music , of legal age, residing at PURDK DAL, ant Rane, > Fisttine Vile arsy AGI DANA DEL WR have read and understood the es) information and the potential health risks explained in this form. Despite such risks, | agree to take the TEACHERS Licensure Examination (Proton on Rew NL, 20% to be administered by the Professional ‘Gata Erato Regulation Commission. | do hereby confirm and declare that | am participating in this event on my own free will and volition. In relation thereto, | hold PRC, entirely free from any liability or responsibility in the event that | contract COVID-19 during the period of the Licensure Examination on WARCH 11, 2074 ; (Oates of Examination) Magen 1, 2024 D Name of Examinee and Signature ate non ae ietea DANTAS PANGILAMON Mass Zot al Name of Witness and SignatureAnnex “B" HEALTH DECLARATION CHECKLIST IMPORTANT REMINDER: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. FILL OUT ENTRIES IN BOLD LETTERS Personal Data: Name:___ PANS MELODY MUSIK. Last Name First Name Middle Name Sex: [J Female Age: 2) [] Male Contact Address: _PU AIH Limaso INGENZO GAC (WOUSENO. & STREE) {@ARANGAY) rownoisTRICT SOUR PRIUPPI Od (errvProvncs) (COUNTRYISTATE) (POsTALZIP COoe) Mobile No/ Telephone No.:_OAISUICUU Email Address: _melodyponcilf@gnail.con Place of Work: KAGATANVINGENZ0 SAGHN ,ZAMODANGA DEL SUR (if applicable) Please check if you have any of the following at present or during the past 14 days: [] Fever 2 37.5°C (oral temperature) [] Cough () Diarrhea [J Headache (Fatigue [) Nausea/Vomiting [ Sore Throat [] Body Aches U Body Weakness UJ Difficulty or [Loss of Taste or Smell [ Runny Nose Shortness of BreathPlease enumerate, if any, cities in the Philippines you have worked, lived, transited in the past 14 days. ONE Please enumerate, if any, foreign countries you have worked, lived, transited in the past 14 days. None. Please check the appropriate box YES NO Did you visit any health worker, hospital, or clinic during the past 14 days? [ } u ‘Were you confined in a hospital or clinic during the past 14 days? (1 u Do you have anyone such as household memberis or close contacls who [] [4 are currently having fever, cough and/or respiratory problems? In the last 14 days, have you been in close contact or exposed to any ul u person suspected of COVID-19? Have you been in Face-to-face contact with a confirmed case within [ ] u 1 meter and for more than 15 minutes? In the last 14 days, have you been in contact with a person confirmed 01 u with COVID-197 When did this person or contact receive a positive RT-PCR test? Have you undergone any test for SARS-Cov? for the past 144days?_ = [ ] (1 Test Type: RT-PCR Rapid Serology Antibody Test Cartridge-based PCR Rapid Antigen Test Rapid ECLIA Antibody Test Others, specify: Results: [] Positive [Negative [Reactive [_]Non-reactive ‘Sample Unfit for Testing [] Pending ‘Where was the test done? Date of Release: No! IF DONE, THE ORIGINAL OFFICIAL RESULT OF RT-PCR SHOULD BE ATTACHED TQ THIS FORM. _IN LIEU OF THE RT-PCR, A CERTIFICATE OF QUARANTINEOR_ITS EQUIVALENT SIGNED _BY_ LICENSED PHYSICIAN (GOVERNMENT _OR_PRIVATE PHYSICIAN) _OR DULY AUTHORIZED LOCAL _OFFICIAL__SHOULD_ BE ATTACHED/SUBMITTED.DECLARATION AND DATA PRIVACY CONSENT FORM | submit that the information | have given is true, correct, and complete. | understand that my failure to answer any question, or any misrepresentation of facts or false/misleading information given by me may be used as a ground for the filing of cases against me in ‘accordance with law. I voluntarily and freely consent to the collection and processing of the ‘above personal information only in relation to the IATF Resolution No. 58, series of 2020, pertinent DOH directives, and PRC health and safety protocols. MELODY MUSIL_PANSIO Name and Signature Date Please be advised that the above information shall only be used in relation to the aforementioned protocols in ‘accordance with the Data Privacy Act and Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concem Act. Verified by (PRC Representative/Proctor): ‘Signature above Printed Name