CHECKLIST FOR PERSONS UNDER MONITORING (PUMs)

(FOR BHERT USE ONLY)

Municipality: ________________________
Barangay: ______________________

NAME: AGE:____ SEX:____ NATIONALITY:___________________ Contact #:

_______________________ ______________
Address: # Persons Other Hypertension: Asthma: Others: Pls
______________________ in the Health Specify
Household: Conditions: ______________
_______ Pls Check Diabetes:
History of Travel to other Exposure: Date Date returned to Province: __________________________
countries: Pls Specify: returned to
________, ________, __________ Phils:
__________
History of Exposure to a Confirmed Date of last Nature of Casual Contact:
2019 nCoV ARD: exposure to Contact:
Confirmed Pls Check Close Contact: With Confirmed case of nCoV within 14 days
YES NO 2019 nCoV Casual: of illness/visited/worked in live animal market in China 14
ARD: Close: days prior to onset of symptoms/worked in hospital where
_________ nCoV infection was reported/health care worker assigned in
_ an environment where Severe Acute Respiratory infection
of unknown cause (etiology) were attended

SYMPTOMS DIARY: Please check accordingly

SYMPTOMS
No FEVER
Diarrhea
symptoms- Equal/ Sore Runny Shortness of
Day Cough or Other
Pls check if More than Throat Nose Breath
Symptoms:
none. 38 C
Pls Specify:
DATE YES NO YES NO YES NO YES NO YES NO
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Any Household contact with clinical symptoms within 14 days of last exposure/contact with the primary case should
be considered a symptomatic and so a probable PUI.

If you develop any of the symptoms listed during the observation period, Please inform any of the contacts below.

Brgy Chairman: Health Worker: RHU/MHO/PHN

Name: Name:
Contact #: Contact #: Contact #:

Reference: Household transmission investigation protocol for 2019 nCoV ARD , version 1.1, Jan 25, 2020,
WHO