Republic of the Philippin

DEPARTMENT OF EDUCA
Region XI

SCHOOL-BASED DRUG ADMINISTRATION

March 04, 2020
Region :
City/Province :

Sex Date of H W
No. Name of Students Age
Birth (cm) (Kg)
M F

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

Accomplished by : Verified by: _____________________________

Class Adviser City Health Nurse
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region XI

ED DRUG ADMINISTRATION FOR SCHISTOSOMIASIS

March 04, 2020
School : MATTI NATIONAL HIGH SCHOOL
Grade Level and Section :
Parent’s
4 P’s
Response Number of
Beneficiary
Address Slip Drugs Date Given Remarks
Yes No Yes No Given

______________________________________ Date Accomplished : ____________________________

City Health Nurse