ANNEX C

Form 1
National School Deworming Month
Deworming Checklist

Province: Davao del Sur

Division: Davao City
District: ________________________________________
Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL
School Address: MATINA, DAVAO CITY
Total Enrollment: __________________________________________________
Grade Level and Section: ____________________________________________
Gender 4ps Handwashing Feeding Toothbrushing Deworming
Name of Child Remarks Actions taken
M F Y N done done done done
1 Ando, Jumer L.
2 Atamosa, John Roy B.
3 Ayoc, Jonel B.
4 Bantayan, Eugene L.
5 Barriga, John Andro M.
6 Bolo, John Paul R.
7 Caburnay, Eduardo Jr. P.
8 Condiman, Edgar Jr.
9 Cumaway, Mark Daniel V.
10 Dawa, Erik M.
11 Dayanan, Christopher C.
12 Enoc, John Paul R.
13 Fajardo, Jomari P.
14 Gregorio, Joel Vince A.
15 Igalan, Louryje V.
16 Labador, Myke Adrian H.
17 Lamanilao, Josh T.
18 Lato, John Paolo B.
19 Lugas, Niño M.
20 Malda, Eric Jay G.
TOTAL

Accomplished by: Noted by:

___________________________________________ __________________________________
Class Adviser Grade Level Head

Date accomplished:___________________
ANNEX C
Form 1
National School Deworming Month
Deworming Checklist

Province: Davao del Sur

Division: Davao City
District: MATINA
Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL (Matina Pangi Campus)
School Address: MATINA PANGI, DAVAO CITY
Total Enrollment: ___
Grade Level and Section: 8 - Apricot
Gender 4ps Handwashing Feeding Toothbrushing Deworming
Name of Child Remarks Actions taken
M F Y N done done done done
1 Ando, Jumer L. ∕
2 Atamosa, John Roy B. ∕
3 Ayoc, Jonel B. ∕ ∕
4 Bantayan, Eugene L. ∕ ∕
5 Barriga, John Andro M. ∕
6 Bolo, John Paul R. ∕
7 Caburnay, Eduardo Jr. P. ∕
8 Condiman, Edgar Jr. ∕ ∕
9 Cumaway, Mark Daniel V. ∕ ∕
10 Dawa, Erik M. ∕ ∕
11 Dayanan, Christopher C. ∕ ∕
12 Enoc, John Paul R. ∕ ∕
13 Fajardo, Jomari P. ∕
14 Gregorio, Joel Vince A. ∕
15 Igalan, Louryje V. ∕ ∕
16 Labador, Myke Adrian H. ∕ ∕
17 Lamanilao, Josh T. ∕
18 Lato, John Paolo B. ∕
19 Lugas, Niño M. ∕ ∕
20 Malda, Eric Jay G. ∕ ∕
TOTAL 20

Accomplished by: Noted by:

APRIL GAY LOVE V. RADAM __________________________________

Class Adviser Grade Level Head

Date accomplished:___________________
ANNEX C
Form 1
National School Deworming M
Deworming Checklist

Province: Davao del Sur

Division: Davao City
District: MATINA
Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL (Matina Pangi Campus)
School Address: MATINA PANGI, DAVAO CITY
Total Enrollment: ___
Grade Level and Section: 8 - Apricot
Gender 4ps Handwashing
Name of Child
M F Y N done
21 Merecido, Revien ∕ ∕
22 Mondejar, John Paul E. ∕ ∕
23 Olan-Olan, Jan Yuri ∕
24 Padilla, Jhunro C. ∕
25 Regondola, Margarito A. ∕
26 Repollo, Joshua Andrie A. ∕ ∕
27 Sabete, Bryce Gabriel G. ∕
28 Sabroso, Michael Joseph F. ∕ ∕
29 Siringan, Jomarie E. ∕
30 Socong, King Jay A. ∕
31 Toston, Jay-ar ∕ ∕
32 Vargas, Kehn Ahron ∕
33 Aguila, Haryette M. ∕
34 Albarico, Frexie Kate E. ∕
35 Albarico, Janelle P. ∕ ∕
36 Altamero, Joyce T. ∕
37 Arnibal, Ariane P. ∕
38 Aro, Charlyn Mae A. ∕ ∕
39 Atamosa, Jessica B. ∕
40 Basadre, Lyzette C. ∕
TOTAL 12 8

Accomplished by:

APRIL GAY LOVE V. RADAM

Class Adviser

Date accomplished:___________________
hool Deworming Month

Feeding Toothbrushing Deworming

Remarks Actions taken
done done done

Noted by:

__________________________________
Grade Level Head
ANNEX C
Form 1
National School Deworming M
Deworming Checklist

Province: Davao del Sur

Division: Davao City
District: MATINA
Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL (Matina Pangi Campus)
School Address: MATINA PANGI, DAVAO CITY
Total Enrollment: ___
Grade Level and Section: 8 - Apricot
Gender 4ps Handwashing
Name of Child
M F Y N done
41 Benedicto, Quisha Nicole R. /
42 Caduldulan, Trisha N. / ∕
43 Cola, Glycel F. / ∕
44 Cruz, Irish C. / ∕
45 De Leon, Ariana Nicole R. /
46 Dullano, Princess Mae G. / ∕
47 Egalan, Erica S. /
48 Fajardo, Mia E. /
49 Gabano, Trixie May T. / ∕
50 Gilbero, Christel Joy M. / ∕
51 Gonzales, Mel Anjella A. /
52 Lopio, Mauren F. / ∕
53 Mansay, Shinna Vie A. /
54 Mante, Jennifer G. /
55 Manzano, Jan Marie S. /
56 Mariquit, Pinky Rose M. /
57 Mata, Christine V. /
58 Nacman, Jezza Marie A. ∕
59 Navaja, Mikylla S. ∕ ∕
60 Notarte, Meca Ella G. ∕ ∕
TOTAL 20

Accomplished by:

APRIL GAY LOVE V. RADAM

Class Adviser

Date accomplished:___________________
hool Deworming Month

Feeding Toothbrushing Deworming

Remarks Actions taken
done done done

Noted by:

__________________________________
Grade Level Head
ANNEX C
Form 1
National School Deworming M
Deworming Checklist

Province: Davao del Sur

Division: Davao City
District: MATINA
Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL (Matina Pangi Campus)
School Address: MATINA PANGI, DAVAO CITY
Total Enrollment: ___
Grade Level and Section: 8 - Apricot
Gender 4ps Handwashing
Name of Child
M F Y N done
61 Ordaneza, Stephanie D. ∕ ∕
62 Pacifico, Erin E. ∕
63 Pamat, Airah S. ∕ ∕
64 Pating, Crizza Mae E. ∕ ∕
65 Ranoco, Mariah Cristina Faith B. ∕ ∕
66 Remollino, Angel Mae D. ∕
67 Responso, Angel A. ∕
68 Sabares, Geraldine C. ∕ ∕
69 Sabroso, Luisa F. ∕ ∕
70 Solis, Christine T. ∕ ∕
71 Soriano, Karel Joy E. ∕ ∕
72 Tantohan, Sheena Mae O. ∕ ∕
73 Tarranza, Jhana Down R. ∕
74
75
76
77
78
79
80
TOTAL 13

Accomplished by:

APRIL GAY LOVE V. RADAM

Class Adviser

Date accomplished:___________________
hool Deworming Month

Feeding Toothbrushing Deworming

Remarks Actions taken
done done done

Noted by:

__________________________________
Grade Level Head
Form 1 - Classroom Level
School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: XI Division: Date: School Year: 2018-2019

School ID: 304359 Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL
Grade Level/ Section: 8 - APRICOT

Provided With Iron Folic Acid Supplements

1st Round 2nd Round REMARKS

LRN NAME OF LEARNER Consent

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

129649100006 Aguila, Haryette M.

129649100009 Albarico, Frexie Kate E.
129649100010 Albarico, Janelle P.
Altamero, Joyce T.
Arnibal, Ariane P.
Aro, Charlyn Mae A.
128263100574 Atamosa, Jessica B.
129649100031 Basadre, Lyzette C.
129649100036 Benedicto, Quisha Nicole R.
Caduldulan, Trisha N.
129640100135 Cola, Glycel F.
128575100036 Cruz, Irish C.
105981100041 De Leon, Ariana Nicole R.
129649090075 Dullano, Princess Mae G.
129649100086 Egalan, Erica S.
Fajardo, Mia E.
129649100100 Gabano, Trixie May T.
129649100105 Gilbero, Christel Joy M.
136651100239 Gonzales, Mel Anjella A.
105134100073 Lopio, Mauren F.
*Consent given Administered by: Noted by:

Class Adviser Grade Level Teacher Date

Form 1 - Classroom Level
School-based Weekly Iron Folic Acid (WIFA) Supplementatio

Region: XI Division: Date: School Year: 2018-2019

School ID: 304359 Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL
Grade Level/ Section: 8 - APRICOT

Provided With Iron Folic Acid

1 Round
st

LRN NAME OF LEARNER Consent

Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2

129649100138 Mansay, Shinna Vie A.

128984100070 Mante, Jennifer G.
129651100188 Manzano, Jan Marie S.
129640100308 Mariquit, Pinky Rose M.
129637100062 Mata, Christine V.
131240101035 Nacman, Jezza Marie A.
129649100149 Navaja, Mikylla S.
129649100153 Notarte, Meca Ella G.
129649100156 Ordaneza, Stephanie D.
131821100028 Pacifico, Erin E.
129649100163 Pamat, Airah S.
129649100168 Pating, Crizza Mae E.
129649100178 Ranoco, Mariah Cristina Faith B.
207558120020 Remollino, Angel Mae D.
129649100181 Responso, Angel A.
129649100190 Sabares, Geraldine C.
129649100193 Sabroso, Luisa F.
Solis, Christine T.
129649100206 Soriano, Karel Joy E.
*Consent given Administered by:

Class Adviser
(WIFA) Supplementation

SCHOOL

Provided With Iron Folic Acid Supplements

2nd Round REMARKS

W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4

Noted by:

Grade Level Teacher Date

Form 1 - Classroom Level
School-based Weekly Iron Folic Acid (WIFA) Supplementatio

Region: XI Division: Date: School Year: 2018-2019

School ID: 304359 Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL
Grade Level/ Section: 8 - APRICOT

Provided With Iron Folic Acid

1 Round
st

LRN NAME OF LEARNER Consent

Y N W1 W2 W3 W4 W1 W2 W3 W4 W1 W2

129649100211 Tantohan, Sheena Mae O.

129649100212 Tarranza, Jhana Down R.

*Consent given Administered by:

Class Adviser
(WIFA) Supplementation

SCHOOL

Provided With Iron Folic Acid Supplements

2nd Round REMARKS

W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4

Noted by:

Grade Level Teacher Date

 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students
Region: XI Name of School: DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL To be filled up by the Vaccination Team
MR
Province/City: DAVAO CITY Division: DAVAO CITY Section: ___________________ Lot No: _______________________
Batch No: _____________________
District/Municipality: ___________________ Date:__________________________ Td
Lot No: _______________________
Batch No.______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Parents' Sick today? Vaccine Given

Response Slip Last ( fever)
Menstrual
Dare of Birth History of allergies Period Potentially
No. Name (1) Complete Address (2) Age Sex (food, meds, previous pregnant Deferred Refusal Reasons for Refusal
MM/DD/YY immunization MR/Td) (for (Y / N)
Y N FEMALES Y N MR Td
only) (R arm) (L arm)

10

11

12

13

14

15
Potentially pregnant means history of sexual contact in the past 4 weeks (for FEMALES only)
Alphabetical, separate male and female, 6 pages per section

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder Name and Signature of Guide
 DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL

SUMMARY OF CONSENT FOR SCHOOL HEALTH SERVICES OFFERED

SCHOOL YEAR 2018-2019

SECTION 8 - APRICOT
ADVISER APRIL GAY LOVE V. RADAM
TOTAL OF MALE STUDENTS 34
TOTAL OF FEMALE STUDENTS 43
TOTAL STUDENTS 77

PARENT/GUARDIAN CHECK UP/ IMMUNIZATION

NAME DEWORMING WIFA (FEMALE)
CONTACT NO. EXAMINATION (GRADE 7)
Ando, Jumer L.
Atamosa, John Roy B.
Ayoc, Jonel B.
Bantayan, Eugene L.
Barriga, John Andro M.
Bolo, John Paul R.
Caburnay, Eduardo Jr. P.
Condiman, Edgar Jr.
Cumaway, Mark Daniel V.
Dawa, Erik M.
Dayanan, Christopher C.
Enoc, John Paul R.
Fajardo, Jomari P.
Gregorio, Joel Vince A.
Igalan, Louryje V.
Labador, Myke Adrian H.
Lamanilao, Josh T.
Lato, John Paolo B.
Lugas, Niño M.
Malda, Eric Jay G.
Merecido, Revien
Mondejar, John Paul E.
Olan-Olan, Jan Yuri
Omega, Jummel
Padilla, Jhunro C.
Panay, Dexter D.
Regondola, Margarito A.
Repollo, Joshua Andrie A.
Sabete, Bryce Gabriel G.
Sabroso, Michael Joseph F.
Siringan, Jomarie E.
Socong, King Jay A.
Toston, Jay-ar
Vargas, Kehn Ahron
Aguila, Haryette M.
Albarico, Frexie Kate E.
Albarico, Janelle P.
Altamero, Joyce T.
Arnibal, Ariane P.
Aro, Charlyn Mae A.
Atamosa, Jessica B.
Basadre, Lyzette C.
Benedicto, Quisha Nicole R.
Caduldulan, Trisha N.
Cola, Glycel F.
Cruz, Irish C.
De Leon, Ariana Nicole R.
Dela Torre, Karen Joy T.
Dullano, Princess Mae G.
Egalan, Erica S.
Fajardo, Mia E.
Gabano, Trixie May T.
Gilbero, Christel Joy M.
Gonzales, Mel Anjella A.
Lopio, Mauren F.
 DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL

SUMMARY OF CONSENT FOR SCHOOL HEALTH SERVICES OFFERED

SCHOOL YEAR 2018-2019

SECTION 8 - APRICOT
ADVISER AGUSTINA E. LUMAIN
TOTAL OF MALE STUDENTS 35
TOTAL OF FEMALE STUDENTS 31
TOTAL STUDENTS 66

PARENT/GUARDIAN CHECK UP/ IMMUNIZATION

NAME DEWORMING WIFA (FEMALE)
CONTACT NO. EXAMINATION (GRADE 7)
ABIG, GWYN SAMARA
ABUGATAL, FRANZEN
ACUESTA, JUSHA
ALEMAN, ELJOHN JHON
ALFANTA, CHARLYN MAE
ARNIBAL, ANGELO
AVILA, RHEAN JOY
BACORNAY, ERNESTO
BERIDO, CHRISNELLE
BERMOY, AIRENE
BOLO, ALEX KYLE
BOLO, RAPHAEL
BUENO, FRANCIS
CABURNAY, ARVIN
CABURNAY, RYAN JECKAIN
CAMACHO, SHEILA
CEJUELA, KINNETH JHON
COLCUIRA, ABEGAIL
CUESTAS, REINFORD
DANCEL, AMIE
DE ASIS, JENNEVIEVE
DELA PEÑA, KYNTH JOSEPH
DELOS SANTOS, KARRELLE
DOMANTAY, JAIME AARON
EBORDE, JOHN RAY
ECHAVIA, STEPHANIE
EGALAN, DAVE JOHN
ESTARDO, SHEEMAE
FEBRIA, NIKKA ROSE
FELISCOSO, SOPHIA
FLORES, JANNICA
GABUT, GLENN
GOLOSINDA, NEIL RHEYDEN
GREGORIO, JIREH KEIGHT
LADECA, MARJORIE
LAPUT, JUANA
LAUSA, JOHN ROE
LLANOS, SHAYNE ANNE
LLAPITAN , AUDREY LYN
LOPIO, MARIS
MALDA, EDRIANNA
MARTINEZ, JETHRO
MASUCOL, DONREX
MONDEJAR, JUNEL
MONGKIL, ANGELO
MONTAÑEZ, MICKAELLA
MONTE DE RAMOS, KRISTINE
NACILLA, OLIVER
NACMAN, JOHN LYNARD
PANAY, JENTLY
PAULINO, CHRISTIAN DAVE
RAMOS, CHEZYL MAE
REMOTIGUE, RENALYN
SALANATIN, AMELIA
SALISE, JERVIL
SEDICOL, ANDREI KENT
SOLIS, MARY GRACE
SORIANO, KLAUI JELL
TACSAN, KENT KARL
TAN, ALEXIS JAMES
TAÑAJURA, MATILDE ROSE
TORREMUCHA, EON HARDRIC
TUGAP, EDIRLYN
VIVAS, LEO JR.
WAOT, SAL STEPEN JAY
WATIN, KIM JOSHUA