Form 1 - Classroom Level NATIONAL SCHOOL DEWORMING DAY

Region: XII
District: Division: SULTAN KUDARAT
Name of School: School ID:
Grade Level: Enrolment: Male:
Section: Female:
TOTAL
DATE OF DEWORMING:
NO. NAME OF CHILD SEX 4Ps BENEFICIARIES DEWORMED REMARKS

(M/F) 4Ps Non-4Ps 4Ps Non-4Ps Reason for not given deworming
Consent not Parent Sick /
returned Refusal Serious
Medical
Condition

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
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31
32
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39

Submit this FORM to the Clinic Teacher for CONSOLIDATION

Form 1 - Classroom Level NATIONAL SCHOOL DEWORMING DAY
40

SUMMARY: SEX ENROLMENT NO. DEWORMED REASON FOR NOT DEWORMIN

4Ps Non-4Ps 4Ps Non-4Ps

Consent not
returned

Sickness /

Condition
refusal
Parent

Medical
Serious
Male
Female
TOTAL

Accomplished by: Noted by:

________________________ ________________________
Class Adviser Class Level Chairman

Date Accomplished: _____________

Submit this FORM to the Clinic Teacher for CONSOLIDATION

 Form 1 - Classroom Level NATIONAL SCHOOL DEWORMING DAY

ARKS
ven deworming
Others (Specify)

Submit this FORM to the Clinic Teacher for CONSOLIDATION

 Form 1 - Classroom Level NATIONAL SCHOOL DEWORMING DAY

T DEWORMING
(Specify)
Others

________
rman

Submit this FORM to the Clinic Teacher for CONSOLIDATION

Form 2 - School Level
Republic of the Philippines
Department of Education
Region XII
Division of Sultan Kudarat
_____________District
NAME OF SCHOOL

NATIONAL SCHOOL DEWORMING ACCOMPLISHMENT REPORT

DATE OF DEWORMING: _______________________

GRADE ENROLMENT NO. OF LEARNERS DEWORMED NO. OF LEARNER

DEWORMED DU
LEVEL

Parent Refusal
Consent not
returned
4Ps Non-4Ps TOTAL 4Ps Non-4Ps TOTAL

M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL

KINDER

GRADE 1

GRADE 2

GRADE 3

GRADE 4

GRADE 5

GRADE 6

TOTAL

Accomplished by: Noted by:

______________________________ ________________________
Clinic Teacher School Head

Date Accomplished: _____________

Form 2 - School Level

Republic of the Philippines

Department of Education
Region XII
Division of Sultan Kudarat
_____________District
______________________________________

NATIONAL SCHOOL DEWORMING ACCOMPLISHMENT REPORT

DATE OF DEWORMING: _______________________

GRADE ENROLMENT NO. OF LEARNERS DEWORMED NO. OF LEARNER

DEWORMED DU
LEVEL
4Ps Non-4Ps TOTAL 4Ps Non-4Ps TOTAL

Consent not
returned

Refusal
Parent
M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL

GRADE 7

GRADE 8

GRADE 9

GRADE 10

GRADE 11

GRADE 12

TOTAL
Form 2 - School Level

Accomplished by: Noted by:

______________________________ ________________________
Clinic Teacher School Head

Date Accomplished: _____________

Sickness / Serious
Medical Condition

Others

ORMED DUE TO
LEARNERS NOT
(Specify)
Form 2 - School Level
Sickness / Serious
Medical Condition

Others

ORMED DUE TO
LEARNERS NOT
(Specify)
Form 2 - School Level
Form 2B - Health Personel Attendance Sheet

Republic of the Philippines

Department of Education
Region XII
Division of Sultan Kudarat
_________District
NAME OF SCHOOL
School Address

LIST OF HEALTH PERSONNEL ASSISTED DURING NAT'L SCHOOL DEWORMING DAY

DATE OF DEWORMING: _______________________

NO. POSITION /
NAME AGENCY MOBILE PHONE NO.
DESIGNATION

10

11

12

13

14

15

16

In case of serious adverse reactions after deworming, the School Head or Clinic in-charge shall NOTIFY the SCHOOL NURSE and OTHER
HEALTH PERSONNEL for immediate management and/or referral.
Form 2B - Health Personel Attendance Sheet

17

18

19

20

Accomplished by: Noted by:

Clinic Teacher School Head

Date Accomplished: _____________

In case of serious adverse reactions after deworming, the School Head or Clinic in-charge shall NOTIFY the SCHOOL NURSE and OTHER
HEALTH PERSONNEL for immediate management and/or referral.
 Form 2B - Health Personel Attendance Sheet

WORMING DAY

SIGNATURE

In case of serious adverse reactions after deworming, the School Head or Clinic in-charge shall NOTIFY the SCHOOL NURSE and OTHER
HEALTH PERSONNEL for immediate management and/or referral.
 Form 2B - Health Personel Attendance Sheet

ool Head

In case of serious adverse reactions after deworming, the School Head or Clinic in-charge shall NOTIFY the SCHOOL NURSE and OTHER
HEALTH PERSONNEL for immediate management and/or referral.
Form 3 - District Level
Republic of the Philippines
Department of Education
Region XII
Division of Sultan Kudarat
NAME OF DISTRICT

NATIONAL SCHOOL DEWORMING ACCOMPLISHMENT REPORT

DATE OF DEWORMING: _______________________

NO. SCHOOL ENROLMENT NO. OF LEARNERS DEWORMED NO. OF LEARNE

DEWORMED D

Consent not
returned
4Ps Non-4Ps TOTAL 4Ps Non-4Ps TOTAL

M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL

10

TOTAL

Accomplished by: Noted by:

District Nurse District Supervisor

Date Accomplished: _____________

Parent Refusal
Sickness /
Serious Medical
Condition
Others

DEWORMED DUE TO
(Specify)

NO. OF LEARNERS NOT

Form 3 - District Level
Form 4 -Division Level

Republic of the Philippines

Department of Education
Region XII
DIVISION OF SULTAN KUDARAT
Kenram, Isulan, Sultan Kudarat 9805

NATIONAL SCHOOL DEWORMING ACCOMPLISHMENT REPORT

MONTH & YEAR OF DEWORMING: _______________________

NO. DISTRICT / ENROLMENT NO. OF LEARNERS DEWORMED NO. OF LEARNERS

HIGH DEWORMED DUE
SCHOOL

Parent Refusal
Consent not
returned
4Ps Non-4Ps TOTAL 4Ps Non-4Ps TOTAL

M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL

10

TOTAL

Accomplished by: Submitted by:

______________________________ MERLYN E. GENTOLEA, DMD

School Deworming Program Coordinator Head, School Health Section

Date Accomplished: _____________

Noted by:
Form 4 -Division Level

MOHALIDIN M. SUAEB, PhD

Chief, School Governance & Operations Division

APPROVED:

RAPHAEL C. FONTANILLA, PhD, CESO V

Schools Division Superintendent
 Form 4 -Division Level

LEARNERS NOT
RMED DUE TO
Serious Medical

(Specify)
Sickness /

Condition

Others

LEA, DMD
Section