Form 1 - Classroom Level 9

NATIONAL SCHOOL DEWORMING DAY

REGION: IV-A DIVISION BATANGAS DISTRICT

SCHOOL ID:
NAME OF SCHOOL
ENROLMENT GRADE LEVEL AND SECTION

BENEFICIARIES DEWORMED
NAME OF THE CHILD REMARKS
4P'S NON-4P'S 4P'S NON-4P'S
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 0 0 0 0

Accomplished by: Noted:

MARITA MARTHA A. CELEMEN

Class Adviser School Principal

Date Accomplished:
ACTION TAKEN
MARITA MARTHA A. CELEMEN
School Principal
Form 2 - School Level

NATIONAL SCHOOL DEWORMING DAY

REGION: IV - A DIVISION BATANGAS

SCHOOL ID:
NAME OF SCHOOL

TOTAL ENROLLMENT NUMBER OF CHILDREN

GRADE LEVEL
4ps non 4Ps 4PS
MALE FEMALE MALE FEMALE MALE

KINDERGARTEN

GRADE 1

GRADE 2

GRADE 3

GRADE 4

GRADE 5

GRADE 6

TOTAL

Accomplished by:

____________________
School Focal Person

Date Accomplished:
 DISTRICT

NUMBER OF CHILDREN DEWORMED

REMARKS
4PS NON 4P'S
FEMALE MALE FEMALE

Noted:

__________________
Principal
Form 3 - District Level

NATIONAL SCHOOL DEWORMING DAY

REGION: IV - A
DIVISION BATANGAS
DISTRICT

TOTAL ENROLLMENT NUMBER OF CHILDREN DEWORMED

SCHOOL ID SCHOOL NAME
4P'S non 4ps 4P'S NON-4P'S
MALE FEMALE MALE FEMALE MALE FEMALE MALE

TOTAL 0 0 0

Accomplished and Submitted by: Approved by:

________________________ JOEL B. LUBIS

District Point Person District Superviso

Date Accomplished:
EN DEWORMED
REMARKS
NON-4P'S
FEMALE

JOEL B. LUBIS
District Supervisor
 ANNEX C: Form
Region IV - CALABARZON
Province BATANGAS
Division BATANGAS
Children Dewormed

No. of Enrolled
DISTRICT Grade Level
Children 4 p's non 4 p's

KINDER
Grade I-VI
Total

Accomplished by: Noted by:

_____________________________
Name and Signature Name and Signature
District Deworming Coordinator School Principal
Date Accomplished Date Accomplished
2
 ANNEX C: Form 4b Division Level Reporting Form

dren Dewormed

consented to
deworming (as Refused deworming (as indicate no consent
total 4 p's + non 4 p's indicate in consent in cosent form) form return
form)

nd Signature
Principal
complished
 Precautionary Measure
(seriously ill, with
abdominal pain, diarrhea,
Adverse Event Reported
who has previous
(type and number)
hypersensitivity with
deworming drug ( annex B
MDAP Guide #1 page 14)
 ANNEX C: Form
Region IV - CALABARZON
Province BATANGAS
Division BATANGAS
Children Dewormed

No. of Enrolled
School Grade Level
Children 4 p's non 4 p's

Grade VII
Grade VIII
Grade IX
Grade X
Total

Accomplished by: Noted by:

______________________ _________________________________
Name and Signature Name and Signature
School Principal
Date Accomplished: Date Accomplished:
2
 ANNEX C: Form 4b Division Level Reporting Form

dren Dewormed

consented to
deworming (as Refused deworming (as indicate no consent
total 4 p's + non 4 p's indicate in consent in cosent form) form return
form)

_____________________________
and Signature
School Principal
ccomplished:
 Precautionary Measure
(seriously ill, with
abdominal pain, diarrhea,
Adverse Event Reported
who has previous
(type and number)
hypersensitivity with
deworming drug ( annex B
MDAP Guide #1 page 14)
 ANNEX C: Form
Region IV - CALABARZON
Province BATANGAS
Division BATANGAS
Children Dewormed

No. of Enrolled
School Grade Level
Children 4 p's non 4 p's

Grade XI
Grade XII
Total

Accomplished by: Noted by:

_____________________________
Name and Signature Name and Signature
District Deworming Coordinator School Principal
Date Accomplished Date Accomplished

2
 ANNEX C: Form 4b Division Level Reporting Form

dren Dewormed

consented to
deworming (as Refused deworming (as indicate no consent
total 4 p's + non 4 p's indicate in consent in cosent form) form return
form)

nd Signature
Principal
complished
 Precautionary Measure
(seriously ill, with
abdominal pain, diarrhea,
Adverse Event Reported
who has previous
(type and number)
hypersensitivity with
deworming drug ( annex B
MDAP Guide #1 page 14)
 Deworming Program
1st Dose
Grade Level Sex Enrollment
No. Dewormed % Enrollment
M
Kinder
F
M
Grade 1
F
M
Grade 2
F
M
Grade 3
F
M
Grade 4
F
M
Grade 5
F
M
Grade 6
F
M
Grade 7
F
M
Grade 8
F
M
Grade 9
F
M
Grade 10
F
M
Grade 11
F
M
Grade 12
F
M
SPED
F
M
ALS
F
M
TOTAL
F
 2nd Dose
No. Dewormed % Enrollment