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SCHOOL BASED DEWORMING CONSENT RE

DIVISION:

CLUSTER/DISTRICT :

Total number of Consent Forms Total Number of Consent forms


Name of Schools
Distributed Returned/retrieved

Noted by:

Principal

SCHOOL BASED DEWORMING CONSENT

DIVISION:

CLUSTER/DISTRICT :

Total number of Consent Forms Total Number of Consent forms


Name of Schools
Distributed Returned/retrieved
TOTAL
Noted by:

Schools District Supervisor


WORMING CONSENT REPORT

Total number of consent forms Total number of consent forms


returned with YES response returned with NO response

Prepared by:

Health / Nutrition Leader

ORMING CONSENT REPORT

Total number of consent forms Total number of consent forms


returned with YES response returned with NO response
Prepared by:

Health / Nutrition Coordinator


NATIONAL SCHOOL DEWORMING MONTH SHOOL

SCHOOL

DISTRICT NAME OF SCHOOL


CONTACT HEALTH/NUTRITION
NURSE ASSIGNED NUMBER COORDINATOR

ARAYAT EAST BATASAN ES CARLA MARIE RHYAN D. MANGUNE 09258187711 H - NANCY GALANG
N - GINA GONZALES

CALUMPANG PS

CAMBA ES

CANDATING ES

CUPANG ES

GUEMASAN ES
LACQUIOS ES

MAPALAD ES

MATAMO ES
WORMING MONTH SHOOLS DIRECTORY

OOL COMMUNITY

CONTACT NUMBER HEALTH LEADER CONTACT NUMBER NDP / MIDWIFE / BNS / BHW ASSIGNED CONTACT NUMBER

09338184356 RACHEL ZAFRA 09165430114 NDP-


09257845214 MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
NDP-
MIDWIFE-
BHW-
TOTAL
TOTAL POPULATION OF
POPULATION OF KINDER TO GRADE
DISTRICT NAME OF SCHOOL % ACC
KINDER TO GRADE 6 GIVEN
6 ENROLLED ALBENDAZOLE

ARAYAT EAST BATASAN ES 357 298 83.47


CALUMPANG 11 10 90.91
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ARAYAT EAST DISTRICT GRAND TOTAL 368 308 83.70
TOTAL TOTAL TOTAL
TOTAL
POPULATION OF POPULATION OF POPULATION OF
POPULATION OF KINDER TO GRADE
GRADE 7 TO GRADE 7 TO % ACC % ACC
KINDER TO GRADE
GRADE 12 GRADE 12 GIVEN 12 GIVEN
12 ENROLLED
ENROLLED ALBENDAZOLE ALBENDAZOLE

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Form 1 - Classroom Level

NATIONAL SCHOOL DEWORMING MONTH


(1ST ROUND & 2ND ROUND)

Region: III Division: SDO PAMPANGA


School ID: _106222_____________
Name of School: _MANIBAUG PARALAYA ELEMENTARY SCHOOL____
Enrolment:____ 38______________________

4Ps Beneficiaries Dewormed


Name of Child
4Ps Non 4Ps 1st Round 2nd Round
1 BULACSO, RENDELL FORD T. ✔
2 CARREON, M-JAY B. ✔
3 DALUSUNG, GABRIEL C. ✔
4 ESTADILLA, MELVIN L. ✔ ✔
5 LAPID, RAVEN D. ✔
6 LOPEZ, BRIX KHIAN E. ✔ ✔
7 MAGAT, NAITAN R. ✔
8 MALIWANAG, JOSE MIGUEL R. ✔ ✔
9 MALONG, JAY-AR ✔
10 MANALOTO, MARK JOHNREY B. ✔
11 MANALOTO, RAKE RAIDEN Q. ✔
12 MARCELO, DANIEL PAUL D. ✔
13 MERCADO, CHARLESTER M. ✔
14 NACINO, PRINCE CHARLES Q. ✔ ✔
15 PARAONDA II, JARDIEL G. ✔
16 PINTANG, JERICO B. ✔ ✔
17 RIVERA, JOWEL L. ✔ ✔
18 SALALAC, JAY ARSON A. ✔
19 SAMONTINA, JORGEN ✔
20 SILOS, ALBBY KYLE D. ✔
21 SILOS, ALVER D. ✔
22 TAYAG, AIDENN A. ✔
23 TONGOL, JERIELHYN B. ✔
24 VALENCIA, GIAN B. ✔
25 VILLAPAÑA, VINCE D. ✔
26 YANGA, JERYCO D. ✔ ✔
27 YUTUC, ROMEO V. ✔
28 CARCABUSO, DANICA S. ✔ ✔
29 CASTRO, ANGELA C. ✔ ✔ ✔
30 CASTRO, JENNICA Q. ✔
31 CATACUTAN, JASMINE CATE ✔ ✔ ✔
32 IBE, KRISSA MAE L. ✔
33 MARFIL, LAIRA MAE P. ✔ ✔
34 QUIZON, TRISHA MAE C. ✔
35 SANTOS, ABBY E. ✔
36 SERRANO, ALLAYSA MAE C. ✔
37 TAPANG, JAZMINE ANN A. ✔
38 YANGA, MABERN B. ✔
39
40

TOTAL 8 30 8 4
Accomplished by:
JOAN R. GARCIA
Class Adviser

Date accomplished:___JANUARY 21, 2020________


Annex B.1

SCHOOL DEWORMING MONTH


ROUND & 2ND ROUND)

District: ______PORAC EAST________

Remarks Action Taken

Refused
Refused
Refused
Refused
Refused

Refused
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Refused
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Refused
Form 2 - School Level

NATIONAL SCHOOL DEWORMING MONTH

Region:III Division: SDO PAMPANGA

School ID: ____________________________________________

Name of School: ______________________________________

Enrolment No. of Children Dewormed


Grade Level
4Ps Non 4Ps Total 1st ROUND

Kinder

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Total

Accomplished by:
HEALTH LEADER

Date accomplished:______________________
Annex B.2

MONTH

District: _______________________________

o. of Children Dewormed Remarks

2nd ROUND

Noted by:
PRINCIPAL
Form 3 - District Level

NATIONAL SCHOOL DEWORMING MONTH

Region: III
Division: PAMPANGA
District: ______________________________________

Enrolment
School ID School Name
4Ps Non 4Ps Total

TOTAL
Accomplished by:
HEALTH/NUTRITION COORDINATOR

Date accomplished:______________________
Annex B.3

SCHOOL DEWORMING MONTH

No. of Children dewormed


Remarks
1st Round 2nd Round

Noted by:
District Supervisor
TOTAL
TOTAL POPULATION OF
POPULATION OF KINDER TO GRADE
CLUSTER NAME OF SCHOOL % ACC
KINDER TO GRADE 6 GIVEN
6 ENROLLED ALBENDAZOLE

CLUSTER 1 TINEJARO HS MAIN XXX XXX XXX


CANDATING HS XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
XXX XXX XXX
ARAYAT EAST DISTRICT GRAND TOTAL XXX XXX XXX
TOTAL TOTAL TOTAL
TOTAL
POPULATION OF POPULATION OF POPULATION OF
POPULATION OF KINDER TO GRADE
GRADE 7 TO GRADE 7 TO % ACC % ACC
KINDER TO GRADE
GRADE 12 GRADE 12 GIVEN 12 GIVEN
12 ENROLLED
ENROLLED ALBENDAZOLE ALBENDAZOLE

357 298 83.47 XXX XXX XXX


150 58 38.67 XXX XXX XXX
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507 356 70.22
Form 1 - Classroom Level Annex B.1

NATIONAL SCHOOL DEWORMING MONTH


(1ST ROUND & 2ND ROUND)

Region:III Division: SDO PAMPANGA District: _________________


School ID: ______________________________
Name of School: _________________________
Enrolment:__________________________ Grade Level & Section: ___________________

4Ps Beneficiaries Dewormed


Name of Child Remarks Action Taken
4Ps Non 4Ps 1st Round 2nd Round
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
TOTAL
Accomplished by: Noted by:

Class Adviser Grade Level Chairman

Date accomplished:______________
Form 2 - School Level

NATIONAL SCHOOL DEWORMING MONTH

Region: III Division: SDO PAMPANGA Cluster:____________________


School ID: ____________________________________________
Name of School: ______________________________________

Enrolment No. of Children Dewormed


Grade Level
4Ps Non 4Ps Total 1st Round 2nd Round
GRADE 7
GRADE 8
GRADE 9
GRADE 10
GRADE 11
GRADE 12
GRADE 13
Total
Accomplished by: Noted by:

Health/Nutrition Leader School Principal

Date accomplished:______________________
Annex B.2

____________________

Remarks

School Principal
Form 3 - District Level

NATIONAL SCHOOL DEWORMING MONTH

Region: III
Division: PAMPANGA
Cluster: ______________________________________

Enrolment
School ID School Name
4Ps Non 4Ps Total

TOTAL
Accomplished by:

Health/Nutrition Leader

Date accomplished:______________________
Annex B.3

NG MONTH

No. of Children dewormed


Remarks
1st Round 2nd Round

Noted by:

School Principal
Annex III

INTEGRATED HELMINTH CONTROL PROGRAM


Adverse Events Following Deworming/Severe Adverse Events

REPORTING FORM

To be filled in by the Physician/Midwife/Barangay Health Worker/Teacher or Parents as needed


during every mass deworming campaign

Region: III Province: PAMPANGA Municipality: ______________________

Service outlet: (Please check and indicate name of RHU, School, Daycare

Barangay Health Station/RHU: _______________________________

School: _______________________________

Day Care center: _______________________

Day of deworming: ________________________ Time of Deworming: ________________________

Chief complaint and


Name of Patient Age Complete Address time of onset of Action Taken Remarks
signs and symptoms

Accomplished by: __________________________________


(Print name and signature)

Date: __________________________
Form 4 - Division Level

NATIONAL SCHOOL DEWORMING DAY

Region: III
Division: PAMPANGA
NO. OF CHILDREN
DISTRICT ENROLMENT DEWORMED
APALIT
ARAYAT EAST
ARAYAT WEST
BACOLOR
BACOLOR
CANDABA EAST
CANDABA NORTH
CANDABA WEST
FLORIDABLANCA EAST
FLORIDABLANCA WEST
GUAGUA EAST
GUAGUA WEST
LUBAO EAST
LUBAO NORTH
LUBAO WEST
MACABEBE EAST
MACABEBE WEST
MAGALANG NORTH
MAGALANG SOUTH
MASANTOL NORTH
MASANTOL SOUTH
MEXICO NORTH
MEXICO SOUTH
MEXICO WEST
MINALIN
PORAC EAST
PORAC WEST
SAN LUIS
STA. ANA
SASMUAN
SAN SIMON
STA. RITA
STO. TOMAS
TOTAL
Accomplished by:

Division Point Person


Date accomplished:______________________
ORMING DAY

REMARKS

Noted by:

LEONARDO D. ZAPANTA
Schools Division Superintendent