Republic of the Philippines

Department of Education
Region IV - A CALABARZON

Form 1 - Classroom Level

National School Deworming Month (NSDM) Round 1

July 2018

District: _____________________________
Name of School:_________________________________ School ID: _____________________
Enrolment: _______________________________ Grade /Section: _________________

Dewormed Consented to Not Dewormed

Deworming
No. Name of Child (BOYS) Refused No consent Precautionary
4Ps Non - 4Ps (as indicated in
consent form) deworming form returned Measure

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: N O T E D:
___________________________ ______________________________
Class Adviser School Deworming Coordinator
Date Accomplished: ___________
epublic of the Philippines
epartment of Education
gion IV - A CALABARZON

ol Deworming Month (NSDM) Round 1

July 2018

School ID: _____________________

Grade /Section: __________________

Adverse Event
________________________________
School Deworming Coordinator
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
Form 2 - School Level (Elementary)
National School Deworming Month (NSDM) Round __
_____________ _______
Month Year
District / Name of School:_____________________________________________________________
No. of Children Dewormed No. of Children NOT Dewormed
Consented to Precautionary measure
Refused Adverse event % Dewormed
Deworming (as No consent (Seriously ill, with abdominal pain,
Grade Enrolment indicated in
Deworming (as reported (yes (total dewormed /
TOTAL 4Ps indicated in form diarrhea, has previous sensitivity with or no) enrollment)
4Ps Non-4Ps consent form) returned deworming drug
& Non-4Ps consent form)
"Annex B" MDAP Guide #1 page 14
Kindergarten 0 0 0 #DIV/0!
Grade 1 0 0 0 #DIV/0!
Grade 2 0 0 0 #DIV/0!
Grade 3 0 0 0 #DIV/0!
Grade 4 0 0 0 #DIV/0!
Grade 5 0 0 0 #DIV/0!
Grade 6 0 0 0 #DIV/0!
TOTAL
(1-6) 0 0 0 0 0 0 #DIV/0!
SPED 0 0 0 #DIV/0!
Grand
0 0 0 0 0 0 #DIV/0!
Total
Accomplished by: N O T E D:
____________________________ _________________________________________
Deworming Coordinator School Nurse School Head
Date Accomplished: __________________
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
Form 2 - School Level (Secondary)
National School Deworming Month (NSDM) Round 1
JULY 2017
Month Year
District / Name of School: RODRIGUEZ IA - MANGGAHAN NATIONAL HIGH SCHOOL

No. of Children Dewormed No. of Children NOT Dewormed

Consented to Refused Precautionary measure ( Seriously ill, Adverse event % Dewormed
Deworming (as No consent
Grade Enrolment TOTAL 4Ps deworming (as with abdominal pain, diarrhea, has reported (yes (total dewormed /
4Ps Non-4Ps indicated in form
& Non-4Ps indicated in the previous sensitivity with deworming or no) enrollment)
consent form) returned
consent form) drug)
Grade 7 215 9 163 172 172 43 80
Grade 8 212 17 141 158 158 54 74.5283018868
Grade 9 209 14 114 128 128 81 61.2440191388
Grade 10 178 7 58 65 65 113 36.5168539326
TOTAL
(7-10) 814 47 476 523 523 291 64.2506142506
Grade 11
Grade 12
TOTAL
(11-12)

SPED
ALS
Grand
814 47 476 523 523 291 64.2506142506
Total
Accomplished by: N O T E D:

_____________________ ABIGAEL C. JACOBE CARMELITA G. OLESCO

 Deworming Coordinator School Nurse School Head
Date Accomplished: AUGUST 2, 2017
___
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
Form 2 - School Level (Secondary)
National School Deworming Month (NSDM) Roun
_____________ _______
Month Year
District / Name of School:_____________________________________________________________

No. of Children Dewormed Consented to No. of Children NOT

Deworming (as Refused
Grade Enrolment TOTAL 4Ps
4Ps Non-4Ps indicated in deworming (as
& Non-4Ps consent form) indicated in the
Grade 7 0 0 0
Grade 8 0 0 0
Grade 9 0 0 0
Grade 10 0 0 0
TOTAL
(7-10) 0 0 0 0 0 0

Grade 11 0 0 0
Grade 12 0 0 0
TOTAL
(11-12) 0 0 #REF! #REF! #REF! #REF!

SPED 0 0 0
ALS 0 0 0
Grand
0 0 #REF! #REF! #REF! #REF!
Total
Accomplished by:

_____________________
Deworming Coordinator School Nurse
Date Accomplished: __________________
 blic of the Philippines
MENT OF EDUCATION
n IV-A CALABARZON
ISION OF RIZAL

eworming Month (NSDM) Round __

________ _______
onth Year
_______________

No. of Children NOT Dewormed

Precautionary measure ( Seriously ill, Adverse event % Dewormed
No consent reported (yes (total dewormed /
with abdominal pain, diarrhea, has
form or no) enrollment)
previous sensitivity with deworming
returned
drug)
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!

#DIV/0!
#DIV/0!

#REF!

#DIV/0!
#DIV/0!
#REF!
N O T E D:

______________________________
School Head
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
Form 2 - School Level (Secondary)
National School Deworming Month (NSDM) Round __
_____________ _______
Month Year
District / Name of School:_____________________________________________________________
Consented
No. of Children Dewormed to No. of Children NOT Dewormed Adverse
Deworming
Refused abdominal event
Grade 7 Enrolment TOTAL 4Ps (as No consent
pain, reported
4Ps Non-4Ps indicated in deworming form
& Non-4Ps consent (as indicated returned
diarrhea, has (yes or no)
in the previous
form)
7-Sampaguita
7-Camia
7-Sunflower
7-Gumamela
TOTAL
GRADE 7
Consented
No. of Children Dewormed to No. of Children NOT Dewormed Adverse
Deworming
Refused abdominal event
Grade 8 Enrolment TOTAL 4Ps (as No consent
pain, reported
4Ps Non-4Ps indicated in deworming form
& Non-4Ps consent (as indicated returned
diarrhea, has (yes or no)
in the previous
form)
8-Diamond
8-Amethyst
8-Emerald
8-Sapphire
TOTAL
GRADE 8
Consented
No. of Children Dewormed to No. of Children NOT Dewormed Adverse
Deworming
Refused abdominal event
Grade 9 Enrolment TOTAL 4Ps (as No consent
pain, reported
4Ps Non-4Ps indicated in deworming form
& Non-4Ps consent (as indicated returned
diarrhea, has (yes or no)
in the previous
form)
9-Love
9-Hope
9-Joy
9-Faith
TOTAL
GRADE 9
Consented
No. of Children Dewormed to No. of Children NOT Dewormed Adverse
Deworming abdominal
Refused event
Grade 10 Enrolment TOTAL 4Ps (as No consent
pain, reported (yes
4Ps Non-4Ps indicated in deworming form
& Non-4Ps consent (as indicated returned
diarrhea, has or no)
in the previous
form)
10-Rizal
10-Aguinaldo
10-Bonifacio
10-Del Pilar
TOTAL
GRADE 10
worming Month (NSDM) Round __
_______ _______
Month Year

%
Dewormed
(total
dewormed /
enrollment)

%
Dewormed
(total
dewormed /
enrollment)

%
Dewormed
(total
dewormed /
enrollment)

% Dewormed
(total
dewormed /
enrollment)