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2019 SHD Form 1
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Republic of the Philippines
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DEPARTMENT OF EDUCATION
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Region ______________
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Division of _____________________
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______________________________________________
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School Name/ID
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SCHOOL HEALTH EXAMINATION CARD
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Name:
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LastFirstMiddle
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Date of Birth:
Birthplace:
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MM/DD/YYYY
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School ID:Region:
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Learner Reference Number (LRN):
Division:
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Parent/Guardian:
Telephone No.:
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Home Address:
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Data Privacy Notice
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 The Department of Education shall engage in the collection of health / medical information for the purposes of tracking, provision of necessary health / medical interventions, and educational purposes. This information shall be processed in accordance with the provisions of the Data Privacy Act and the Data Privacy Policies of the Department.
This information shall be stored and held confidentially in accordance with the provisions of the Basic Education Act and may only be shared with other government agencies or third parties subject to Data sharing agreements and data privacy requirements for legitimate purposes only.
For inquiries, requests and concerns regarding your data privacy rights, please contact the data privacy compliance officer, team of the school, schools division office or regional office concerned.
I hereby authorize the Department of Education to use, collect, and process the information for the purposes of the above stated.
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 Ang DepEd ay mangongolekta ng impormasyong pangkalusugan/medikal para sa mga layunin ng pagsubaybay, pagbibigay ng kinakailangang mga interbensyon sa kalusugan/medikal, at mga layuning pang-edukasyon. Ang impormasyong ito ay ipoproseso alinsunod sa mga probisyon ng Data Privacy Act at ng Data Privacy Policy ng DepEd.
Ang impormasyong ito ay mananatiling kumpidensyal alinsunod sa mga probisyon ng Basic Education Act at maaari lamang ibahagi sa ibang mga ahensya ng gobyerno o mga ikatlong partido na napapailalim sa Data Sharing Agreement at mga kinakailangan sa privacy ng data para sa mga lehitimong layunin lamang.
Para sa mga katanungan, kahilingan, at alalahanin tungkol sa iyong mga karapatan sa privacy ng data, mangyaring makipag-ugnayan sa data privacy compliance officer, team ng paaralan, schools division office, o regional office na kinauukulan.
Sa pamamagitan nito, pinahihintulutan ko ang DepEd na gamitin, kolektahin, at iproseso ang impormasyon para sa mga layunin ng nakasaad sa itaas.
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Name and Signature of Child Name and Signature of Parent
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