Annex ABC Downloadable Forms-1
Annex ABC Downloadable Forms-1
Annex ABC Downloadable Forms-1
Pursuant to Department of Health (DOH) Administrative Order 2020-0015 otherwise known as the
“Guidelines on the Risk-Based Public Health Standards for COVID-19 Mitigation” and adopting the PRB
of Medicine Resolution Nos. 17 and 21 (s. 2020), the Commission prescribes the following strict health
protocols in addition to PRC Memorandum Nos. 24 and 28 (s. 2020), particularly in the conduct of all
licensure examinations during the pandemic:
I. COVERAGE
This Memorandum Order shall apply to licensure examinations during the COVID-19 pandemic.
1. Examinees and examination personnel who fall under the following groups 1 shall undergo
the mandatory RT-PCR testing from any of the DOH accredited facilities 3-5 days before the
examination date/s:
In this case, examinees and examination personnel shall be required to submit the result of
their RT-PCR tests. Only those examinees with negative results shall be allowed to take the
examination.
1
According to DM 2020-258A or the Updated Interim Guidelines on Expanded Testing for COVID-19
2. However, if an examinee or examination personnel does not fall in the above- mentioned
conditions, he/she may undergo a 14-day quarantine period wherein he/she is asymptomatic
for at least 14 days prior to the scheduled examination date/s, provided that he/she has no
close contact or exposure to the aforementioned cases, he/she shall be allowed to take/assist
the examination in the absence of RT-PCR test. A Certificate of Quarantine or its
equivalent signed by any of the following shall be submitted instead:
2.1. Any licensed Physician (government or private physician);
2.2. Municipal Health Officer, Provincial Health Officer or City Health Officer;
2.3. Barangay Officer visiting the examinee’s residence attesting that he/she has been in
quarantine for 14 days.
3. Examinees coming from other countries should be able to quarantine for 14 days or provide
a negative RT-PCR test result whichever is shorter.
4. All examination personnel including the PNP/PRC Security Officers assigned in the
Confidential Printing Room (CPR) and those assigned to transport and secure the test
materials in various testing venues shall undergo the RT-PCR test to assure their safety as
well as to those involved in the administration of examination. Only those mentioned
personnel with negative RT-PCR result and Certificate of Quarantine shall be allowed to
assist/administer the same.
Examination personnel shall exclude the following vulnerable individuals in order to reduce
their exposure and prevent infection in consonance with the Omnibus Guidelines On the
Implementation of Community Quarantine in the Philippines:
1. the elderly;
2. individuals with underlying conditions; and
3. pregnant women
1. All examinees and examination personnel shall enforce the following precautionary
measures among themselves:
1.1 Observe physical distancing of two (2) meters between examinees. Examinees shall be
restricted to their assigned seat;
1.2 Wear face mask (at least 3-ply surgical mask, preferably N95 mask) and face shield
at all times;
1.3 Bring 70% ethyl alcohol for hand disinfection;
1.4 Wear latex gloves for exam personnel handling the test questionnaires.
2. Examinee shall submit the duly accomplished Informed Consent (Annex A) and Health
Declaration (Annex B) forms with the Notice of Admission (NOA) and the negative RT-
PCR test result/Quarantine Certificate to the proctor on the examination day.
Informed Consent and Health Declaration Forms can be downloaded on the PRC official
website (www.prc.gov.ph);
3. Examinees and examination personnel shall bring their own meals (pre-packed meal/snack
and drink) to be eaten during breaks, while being in their assigned seats.
Note: Face masks will only be removed when taking meals or drinks.
4. Examinees shall bring their own pens, pencils and erasers. Borrowing from seatmate is not
allowed to prevent cross-contamination;
5. Talking and loitering are prohibited in the hallways or in the examination room.
1. The map of the building (showing layout of the entrance/exit points and comfort rooms) will
be available on the official PRC website and Facebook page and shall be printed in the NOA
of examinees for reference;
3. Examinees will be apprised regarding the specific DESIGNATED ENTRANCE and EXIT
gate to be used;
4. The following announcement and infographics will be posted on the testing venues and PRC
website:
1. Foot bath with 10% Chlorine solution shall be available at the entrance gate;
2. Physical distancing shall be strictly observed in the queuing of the examinees entering the
testing venues;
3.1 Only examinees with temperature of less than or equal to 37.5 degrees Celsius
(≤37.5℃) shall be allowed to enter the testing venue;
3.2 Examinee with temperature of more than 37.5 degrees Celsius (37.5℃) shall be
referred to the Building Supervisor, who shall refer the concerned examinee to an
onsite medical doctor for assessment. Examinee will not be allowed to take the rest of
the examination.
4. 70% isopropyl or ethyl alcohol shall be available at the entrance gate for hand disinfection.
Hand soap or 70% isopropyl or ethyl alcohol shall be provided also in all comfort rooms;
5. Examinees shall proceed immediately to their designated examination rooms after the
thermal scanning/screening.
1.2 Medical personnel and/or on-call physician. The contact details of the on-call
physician and DOH Focal Person shall be known to the Examination Coordinator and
Building Supervisor in the event that an examinee/personnel shows signs of COVID-
19 during the licensure examination;
1.3 Stand-by ambulance or PRC vehicle that will transport the concerned
examinee/personnel to the hospital as referred by the DOH Focal Person. This
ambulance/PRC vehicle shall be disinfected before and after its use.
2. In the event that an examinee manifests the COVID-19 symptoms such as temperature
higher than 37.5 degrees Celsius (37.5℃), colds, cough, other flu-like symptoms and
difficulty of breathing, the following must be observed:
2.1.1 The examinee shall not be allowed to enter the testing site. He/she shall be
advised to go home to undergo necessary quarantine or to seek medical treatment.
His/her health form shall be collected at the gate and shall be endorsed to the
Regional Office for reporting;
2.1.2 The examinee shall be advised to defer taking the licensure examination, but shall
be allowed to take the same immediately succeeding scheduled licensure
examination.
2.2.1 The proctors shall ensure that all health protocols are observed during the
examination proper;
2.2.3 Upon advice of the on-site medical personnel or on-call physician, the Building
Supervisor shall report the case to the DOH Focal Person and get a referral
hospital for the examinee’s immediate medical attention. A separate exit gate
shall be provided for his/her transport to the said hospital;
2.2.4 The name of the examinee, examination room number, seat number, and seat plan
shall be forwarded to the building supervisor who shall then submit a report to the
Regional Director and notify the Licensure Office and the Board. In addition, the
people who had “close contact” with the examinee shall be properly reported.
2.3.1 All examinees shall be required to download and fill-out a Post Examination
Health Surveillance Form, attached as Annex “C” and submit the same fourteen
(14) days after the examination through the designated Regional Offices’ email
address. The said form is downloadable on PRC official website.
The Regional Offices shall submit a report to Licensure Office who shall
collate/summarize and submit to the Board for information.
2.3.2 All examinees and examination personnel inside the examination room who had
close contact with the patient (manifesting symptoms of COVID-19) shall also be
advised to undergo RT-PCR test or 14-day home quarantine after the
examination.
2.3.3 The Regional Offices shall create an email address specifically reserved for this
purpose which will be disseminated to the examinees by the proctors/room
watchers during the examination day.
1. For examinees coming from regions outside the National Capital Region (NCR) – all
concerned shall abide the respective Local Government Unit (LGU) implemented protocols
and directives issued by the Inter-Agency Task Force on Emerging Infectious Diseases
(IATF-EID) with regard to the interzonal and intrazonal movement of persons such as RT-
PCR test, Rapid test, 14-day quarantine, IATF pass, travel pass and the like;
2. The examinee who fails to take his/her scheduled licensure examination (examinee’s name
is already included in the Room Assignment), shall be allowed to take it immediately
succeeding scheduled licensure examination provided that he/she has the following valid
reason/s:
2.1 Health Reason: The examinee shall submit a letter to the Commission and the
concerned Board together with a notarized medical certificate;
2.2 Travel Restriction: The examinee shall submit a letter with attached official letter of
restriction from the LGU concerned.
INFORMED CONSENT
ON THE POTENTIAL RISK ASSOCIATED WITH TAKING THE
BOARD PROFESSIONAL TEACHER LICENSURE EXAMINATION
(profession)
You are given this informed consent form because the Professional Regulation
Commission (PRC) and Professional Regulatory Board of PROFESSIONAL TEACHER
(profession)
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
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:
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 (IATF) 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.
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.
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.prc.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.
Thank you.
CERTIFICATE OF CONSENT
In relation thereto, I hold PRC, entirely free from any liability or responsibility in the event that
I contract COVID-19 during the period of the Licensure Examination on
OCTOBER 2, 2022 .
(Date/s of Examination)
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.
Personal Data:
Please check if you have any of the following at present or during the past 14 days:
[ ] Fever ≥ 37.50C (oral temperature) [ ] Cough [ ] Diarrhea
[ ] Headache [ ] Fatigue [ ] Nausea/Vomiting
[ ] Sore Throat [ ] Body Aches [ ] Body Weakness
[ ] 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.
____________________________________________________________________________
____
Please enumerate, if any, foreign countries you have worked, lived, transited in the past
14 days.
Please check the appropriate box
YES NO
Did you visit any health worker, hospital, or clinic during the past 14 days? [] [ ]
Were you confined in a hospital or clinic during the past 14 days? [] [ ]
Do you have anyone such as household member/s or close contact/s who are [ ] [ ]
currently having fever, cough and/or respiratory problems?
In the last 14 days, have you been in close contact or exposed to any [] [ ]
person suspected of COVID-19?
Have you been in Face-to-face contact with a confirmed case within [ ] []
1 meter and for more than 15 minutes?
In the last 14 days, have you been in contact with a person confirmed [ ] [
] with COVID-19?
When did this person or contact receive a positive RT-PCR test?
Have you undergone any test for SARS-Cov2 for the past 14 days? [ ] []
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
Note:
IF DONE, THE ORIGINAL OFFICIAL RESULT OF RT-PCR SHOULD BE ATTACHED TO
THIS FORM. IN LIEU OF THE RT-PCR, A CERTIFICATE OF QUARANTINE OR 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
I submit that the information I have given is true, correct, and complete. I 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.
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 Concern Act.
Instructions: Please continue to follow social distancing and the wearing of face mask
even after the exam. You are required to send an email at the official email address of the
Regional Office where you take your licensure examination 15 days after the last
examination date. Please provide truthful information relative to your health status.
Dear PRC,
Name:
Testing Venue:
Room No:
Seat No:
After completing the message, you will receive an acknowledgment and/or further
instructions from PRC.