Form 1- Classroom Level Female learners per classroom

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:
1st Round 2nd Round
Consent
July August September January February March
No. NAME OF LEARNER
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Y N
(date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date)

Total
Consent Given* Codes for reasons why W
Please indicate the date of administration* Submitted by: Noted by:

Class Adviser Date Grade Level Chairman Date

 Reason why
WIFA is not given
Remarks
Please indicate
codes

for reasons why WIFA is not given :

1. not dewormed
2. on therapeutic treament for anemia
3. with persistent gastric reaction like gastric discomfort
 Form 2A- Grade Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 Reporting Month:

Grade Level 7 8 9 10 ALS

Region: Division: District: School Year:

School ID: Name of School: Address: Date:

Total Enrolment Given WIFA Not Given WIFA Total No. of WIFA is
Name of Section/ Total No. Total No. Supplements Supplements not given (based in
Remarks
Classroom of enrolled of female codes)
Number % Number %
Learners Learners 1 2 3

Total:
Submitted by: Validated by: Noted by:

Grade Level Chairman School Nurse Principal

Date: Date: Date:

 Reporting Form 2b- School Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

Region: III Division: Gapan City District: South

School ID: 501200 Name of School: Marelo Integra Address: Marelo, Gapan City

Total Enrolment Given WIFA Not Given WIFA Total No. of WIFA is not give
Total No. of Total No. Total No. Total No. of Supplements Supplements based in codes
Grade Level
Sections/ of enrolled of female Female learners
Number % Number % 1 2 3
Classrooms Learners Learners with consent
Gr. 7 1 49 22 11 11 50 11 50
Gr. 8 1 24 9 5 4 55.56 4 44.44
Gr. 9 1 27 11 5 5 45.45 6 54.55

Submitted by: Validated by: Noted by:

CATHERINE F. MENDOZA ANN FRANCES M. DE GUZMAN MYRNA M. BORJA

WIFA Supplemental Point Person School Nurse Principal II
September 30, 2019
Date Date
n
Reporting Month: July-Septempber 2019

Date: September 30, 2019

Remarks