Teachers Clearance SHS

1. Republic of the Philippines
Department of Education
Caraga Administrative Region
Schools Division of Siargao
DAPA NATIONAL HIGH SCHOOL
Dapa, Surigao del Norte
TEACHER’S CLEARANCE
The Schools Division Superintendent
Division of Siargao
Dapa, Surigao del Norte
Through Channel
Sir/Madam:
I have the honor to inform you that I have satisfactorily accounted for money and
property responsibilities for which I was responsible in this school and that all reports
required of my work were submitted on the dates shown below:
1. Textbooks and another IM’s issuedreturned: ___ 9. IPCR filed: ____
2. Statement of Assets and Liabilities Net Worth filed: OK 10. Form 211 submitted: ___
3. School Form 1 (Completed): ___ 11. Form 2: ___________
4. SF 5, Report on Promotion & Level of Proficiency: _____ 12. SF 6: _____
5. CS Form 48 submitted: ____ 13. Classroom key turnover: ____
6. Income Tax Return/W2 Filed: ______ 14. Records of Classroom Observation Filed: ___
7. Report of Collection: ____ 15. BPS Form 138 A completed: ___
8. BPS Form 137 A fully accomplished and filed: ____ 16. Early Registration Report submitted: OK
Very truly yours,
MA. LYNDA ANDALES SAJOL
Signature over Printed Name
Certified Correct: Designation: Teacher II
DEXTER L. CONSIGNA PEDRO B. MINDAÑA BLAISE R. SUMAMPONG
SHS Supply Officer-Designate SHS Registrar/Records Officer SHS Administrative Officer- Designate
_____________________ CHERRY IRENE E. AGAN, MA JORIS T. SULIMA
Division Health Personnel SHS Dept. Head School Planning-Designate
APPROVED:
ROLAN C. RAZA, MA
School Principal IV
__________________________________________________________________________________________
1st Endorsement
Dapa National High School
April 7, 2017
Respectfully forwarded to the Schools Division Superintendent, the first and last day of
service of this teacher was on June 13, 2016 and April 7, 2017 respectively. The foregoing
statements are correct and complete clearance is hereby granted. He / She is entitled to
____________ days proportional vacation salary.
ROLAN C. RAZA, MA
School Principal IV

2. Form No. 86
HEALTH EXAMINATION RECORD
Name: MA. LYNDA ANDALES SAJOL Office: Dapa National High School
Address: Dapa, Surigao del Norte Type of Work: Teaching
Age: 23 Weight: 47 Civil Status: Married
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1. Height: Weight: 9. Eyes: ______________________________
2. Respiratory System: ___________________________ 10. Color Perception: ___________________
____________________________________________ ______________________________
FLUORAGRAPHY:
Right Lung: _______________________ 11. Vision:
_______________________ Without Glasses: Far – R _____________
L _____________
Near – R _____________
Left Lung: ________________________ L _____________
3. Circulatory System: ___________________________ 12. Ears: _______________________________
___________________________________________ _______________________________
Blood Pressure: 13. Hearing: ____________________________
Systolic: ________________________________ ____________________________
Diastolic: _______________________________
Pulse: 14. Nose: _______________________________
Sitting _________________________________ _______________________________
Agility Test _____________________________
After 2 minutes _________________________ 15. Throat: _____________________________
4. Digestive System: ____________________________ 16. Tooth & Gums: _______________________
______________________________________
5. Genito Urinary: ______________________________ 17. Immunization: ________________________
______________________________________ ________________________________
Urinalysis: _____________________________ ________________________________
6. Skin: _______________________________________ 18. Remarks: ____________________________
_______________________________________ ____________________________
7. Locomotor System: ___________________________ 19. Recommendation: ____________________
______________________________________ ________________________________
________________________________
8. Nervous System: ______________________________ ________________________________
_______________________________________
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Date: ______________________
Place: Dapa, Surigao del Norte ______________________________________
(Signature of Employee)
_______________________________________
Medical Officer/ Signature over Printed Name