CONSOLIDATED ANNUAL PHYSICAL EXAMINATION & LABORATORY RESULTS OF TEACHING & NON-TEACHING PERSONNEL

SY: _____________

DISTRICT/SECONDARY SCHOOL: ___________________________________________

DIAGNOSTIC EXAMINATIONS Others PHYSICIAN'S FINDINGS
Date Chest Sputum Exam Date Urinalysis (Based from Form 86)
NAME OF TEACHER TP NTP
X-Ray (AFB) (UA) Remarks Recommendation

Prepared by: Noted by: Legend:

TP=Teaching Personnel
Nurse / Clinic Teacher PSDS / DPIC / SSP NTP=Non-Teaching Personnel
(Cel #: ________________ ) (Cel #: ________________ )
 Top Ailments of T/NTP

SY : __________

Name of District : Total No. of Teachers :

Name of Secondary Total No. of Non-Teaching Personnel :
School (JHS / SHS) : Total :

Rank Ailments No. of Cases %

Prepared by:
Nurse II / Clinic Teacher