Form 1- Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: __________ Division: __________ Date: ____________________School Year: ___________________

School ID:________ Name of School:__________ _____________________
Grade Level/Section: _________ No. of Students Enrolled:_________ No. of Female Learners:_________ Address: _______________________________________

Provided With Iron Folic Acid Supplements

CONSENT 1st Round 2nd Round
LRN LEARNER
July August September January February March
Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
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
*Consent Given Administered by: Noted by:

____________ ____________
Class Adviser Date School Principal Date
 Annex A1

y Iron Folic Acid (WIFA) Supplementation

____ No. of Female Learners:_________ Address: ________________________________________

REMARKS
Form 1- Classroom Level Annex A1

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: __________ Division: __________ Date: ____________________School Year: ___________________

School ID:________ Name of School:__________ _____________________
Grade Level/Section: _________ No. of Students Enrolled:_________ No. of Female Learners:_________ Address: ________________________________________

Provided With Iron Folic Acid Supplements

CONSENT 1st Round 2nd Round
LRN LEARNER REMARKS
July August September January February March
Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
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
*Consent Given Administered by: Noted by:

____________ ____________
Class Adviser Date School Principal Date
f Female Learners:_________ Address: ________________________________________
Form 1- Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: __________ Division: __________ Date: ____________________School Year: ___________________

School ID:________ Name of School:__________ _____________________
Grade Level/Section: _________ No. of Students Enrolled:_________ No. of Female Learners:_________ Address: ________________________________________

Provided With Iron Folic Acid Supplements

CONSENT 1st Round 2nd Round
LRN LEARNER
July August September January February March
Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
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
*Consent Given Administered by: Noted by:

____________ ____________
Class Adviser Date School Principal Date
 Annex A1

y Iron Folic Acid (WIFA) Supplementation

____ No. of Female Learners:_________ Address: ________________________________________

REMARKS
____________
Form 1- Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: __________ Division: __________ Date: ____________________School Year: ___________________

School ID:________ Name of School:__________ _____________________
Grade Level/Section: _________ No. of Students Enrolled:_________ No. of Female Learners:_________ Address: _______________________________________

Provided With Iron Folic Acid Supplements

CONSENT 1st Round 2nd Round
LRN LEARNER
July August September January February March
Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
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
*Consent Given Administered by: Noted by:

____________ ____________
Class Adviser Date School Principal Date
 Annex A1

y Iron Folic Acid (WIFA) Supplementation

____ No. of Female Learners:_________ Address: ________________________________________

REMARKS
Form 1- Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: __________ Division: __________ Date: ____________________School Year: ___________________

School ID:________ Name of School:__________ _____________________
Grade Level/Section: _________ No. of Students Enrolled:_________ No. of Female Learners:_________ Address: _______________________________________

Provided With Iron Folic Acid Supplements

CONSENT 1st Round 2nd Round
LRN LEARNER
July August September January February March
Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
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
*Consent Given Administered by: Noted by:

____________ ____________
Class Adviser Date School Principal Date
 Annex A1

y Iron Folic Acid (WIFA) Supplementation

____ No. of Female Learners:_________ Address: ________________________________________

REMARKS
Form 1- Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: __________ Division: __________ Date: ____________________School Year: ___________________

School ID:________ Name of School:__________ _____________________
Grade Level/Section: _________ No. of Students Enrolled:_________ No. of Female Learners:_________ Address: _______________________________________

Provided With Iron Folic Acid Supplements

CONSENT 1st Round 2nd Round
LRN LEARNER
July August September January February March
Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
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
*Consent Given Administered by: Noted by:

____________ ____________
Class Adviser Date School Principal Date
 Annex A1

y Iron Folic Acid (WIFA) Supplementation

____ No. of Female Learners:_________ Address: ________________________________________

REMARKS
Form 2A Annex 2A
SCHOOL-BASED WEEKLY IRON FOLIC-ACID (WIFA) SUPPLEMENTATION

ROUND 1 ROUND 2

GRADE 7 8 9 10 11 12

REGION: _________________ DIVISION: _________________ DATE: ___________ SCHOOL YEAR: ___________________

SCHOOL ID: ___________________________ NAME OF SCHOOL: _______________________________ ADDRESS: _______________________________

Enrolment Given WIFA Supplements Not given WIFA Supplements Remarks

SECTION Total No. of enrolled Total No. of Female Numbers % Numbers % (Reason why WIFA is Not Given)
learners learners

#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
#DIV/0! #DIV/0!
Administered by: Noted By:

Class Adviser School Principal

Date: ___________ Date: ___________

Form 2B Annex 2B
SCHOOL-BASED WEEKLY IRON FOLIC-ACID (WIFA) SUPPLEMENTATION

ROUND 1 ROUND 2

GRADE 7 8 9 10 11 12

REGION: _________________ DIVISION: _________________ DATE: ___________ SCHOOL YEAR: ___________________

SCHOOL ID: ___________________________ NAME OF SCHOOL: _______________________________ ADDRESS: _______________________________

Enrolment Given WIFA Supplements Not given WIFA Supplements Remarks

GRADE Total No. of enrolled Total No. of Female Numbers % Numbers % (Reason why WIFA is Not Given)
learners learners

7 #DIV/0! #DIV/0!
8 #DIV/0! #DIV/0!
9 #DIV/0! #DIV/0!
10 #DIV/0! #DIV/0!
TOTAL #DIV/0! #DIV/0!
#DIV/0! #DIV/0!
11 #DIV/0! #DIV/0!
12 #DIV/0! #DIV/0!
TOTAL #DIV/0! #DIV/0!

GRAND
TOTAL #DIV/0! #DIV/0!

Submitted By: Noted By:

Health Coordinator School Principal

Date: ___________ Date: ___________

Validated By:

School Nurse

Date: ___________
Form 3A- District Level
SCHOOL-BASED WEEKLY IRON FOLIC-ACID (WIFA) SUPPLEMENTATION

ROUND 1 ROUND 2

GRADE 7 8 9 10 11 12

REGION: _________________ DIVISION: _________________ SCHOOL YEAR: ___________________

Enrolment Given WIFA Supplements Not given WIFA Supplements

Total No. of enrolled Total No. of Female

SCHOOL ID SCHOOL Numbers % Numbers %
learners learners

1) #DIV/0! #DIV/0!
2) #DIV/0! #DIV/0!
3) #DIV/0! #DIV/0!
4) #DIV/0! #DIV/0!
5) #DIV/0! #DIV/0!
6) #DIV/0! #DIV/0!
7) #DIV/0! #DIV/0!

Submitted By: Approved By:

Health Coordinator School Principal

Date: ___________ Date: ___________

Validated By:

School Nurse
Date: ___________
 Annex 3A

HOOL YEAR: ___________________

Remarks

(Reason why WIFA is Not Given)