SBFP Form 1 (2021)

Department of Education
Region III

Master List Beneficiaries for School-Based Feeding Program (SBFP) (SY2021-2022)

Division/Province: Name of Principal :

City/ Municipality/Barangay : Name of Feeding Focal Person :
Name of School / School District :
School ID Number:

Nutritional Beneficiary
BMI for Parent's
Date of Weighing / Age in Weight Height 6 y.o. Status (NS) Dewormed?
consent for
Participation of SBFP in
No. Name Sex Grade/ Section Date of Birth (MM/DD/YYYY) Measuring Years / (yes or in 4Ps Previous REMARKS
(MM/DD/YYYY) Months (Kg) (cm) and no) milk? (yes or no) Years (yes or
above (yes or no)
no)
BMI-A HFA
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Prepared by: Approved by:

__________________________ School Head

Feeding Focal Person

Note: This form shall be prepared by the school before the start of feeding to be compiled by the SDO.
Keep columns 6-12 blank if nutritional assesment is still suspended.
SBFP Form 2 (2021)
Department of Education
Region III

SCHOOL-BASED FEEDING PROGRAM (SBFP) SUMMARY OF BENEFICIARIES & START OF FEEDING (SY 2021-2022)
Division/Province: PAMPANGA
City/ Municipality/Barangay :
Name of School / School District :
School ID Number:
Date of Start of Feeding:
Last Mile School: ___Y ___N
Nutritional Status at Start/End of Feeding No. of Secondary Targets No. of 4 No. of 4 Ps No. of Pupils
Learners Beneficiaries who are
SW W N OW+O SS S N T No. of Pupils- No. of No. of No. of Dewormed beneficiaries in
Number of Undernourished School at-risk-of- Stunted/ Indigent Indigenous previous years
Children by Grade Level dropping-out Severely Learners Peoples (IPs) (Repeaters)
(PARDOs) Stunted

1. Kinder

2. Grade I

3. Grade II

4. Grade III

5. Grade IV

6. Grade V

7. Grade VI

8. SPED

Total

Prepared by: Approved by:

MILA M. DE LEON IRENE N. MARQUEZ

SBFP DepEd Focal School Head

Note: This form shall be prepared by the school before the start of feeding and after feeding, to be compiled by the SDO, and for final compilation by the RO, for submission to DepEd BLSS-SHD
 Date Feeding
Started/Ended

sion to DepEd BLSS-SHD

 SBFP Form 3 (2021)
SCHOOL-BASED FEEDING PROGRAM
RECORD OF DAILY FEEDING

FOR THE MONTH OF ______________________ , SY _____________

Region
Division School:
District Grade: Section _____________________
School ID Number:

NAME OF PUPIL DATE ACTUAL FEEDING

REMARKS

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248
249
250
TOTAL:
Prepared by:

____________________________
B. Deworming D. Actual Feeding
Feeding Teacher
( x ) - not dewormed (H ) - Present, served with Hot meals
Approved by: ( √ ) - dewormed (M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
School Head (H2/M2/(H/M2)) - Present, served twice

Note: This form shall be prepared by the school to be consolidated using the Revised OKD Form A.
 SBFP Form 3 (2021)
SCHOOL-BASED FEEDING PROGRAM
RECORD OF DAILY FEEDING

FOR THE MONTH OF ______________________ , SY _____________

Region
Division School:
District Grade: Section _______________
School ID Number:

NAME OF PUPIL DATE ACTUAL FEEDING

16 17 18 19 20 21 22 23 24 25
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249
250
TOTAL:
Prepared by:

____________________________
B. Deworming D. Actual
Feeding Teacher
( x ) - not dewormed (H ) - Present, served with Hot meals
Approved by: ( √ ) - dewormed (M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
School Head (H2/M2/(H/M2)) - Present, served twice

Note: This form shall be prepared by the school to be consolidated using the Revised OKD Form A.
_______

Section _____________________

REMARKS

26 27 28 29 30
D. Actual Feeding
 SBFP Form 3 (2021)
SCHOOL-BASED FEEDING PROGRAM
RECORD OF DAILY FEEDING

FOR THE MONTH OF ______________________ , SY _____________

Region
Division School:
District Grade: Section _____________________
School ID Number:

NAME OF PUPIL DATE ACTUAL FEEDING

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240
241
242
243
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245
246
247
248
249
250
TOTAL:
Prepared by:

____________________________
Feeding Teacher / School Nurse
Approved by:
School Head
B. Deworming D. Actual Feeding
( x ) - not dewormed (H ) - Present, served with Hot meals
( √ ) - dewormed (M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
(H2/M2/(H/M2)) - Present, served twice

Note: This form shall be prepared by the school to be consolidated using the Revised OKD Form A.
 REMARKS

45
 SBFP Form 3 (2021)

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region
Division School:
District Grade:
School ID Number:

DATE ACTUAL FEEDING

NAME OF PUPIL

46 47 48 49 50 51
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page 2
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TOTAL:

Prepared by:

Feeding Teacher

Approved by:

School Head

Note: This form shall be prepared by the school to be consolidated using the Revised OKD Form A.

page 2
___

Section _____________________
hool ID Number:

ATTENDANCE
DAYS Feeding Percentage
RECEIVED Days
REMARKS

page 2
page 2
page 2
page 2
page 2
page 2
page 2
SBFP Form 5 (2020)

DEPARTMENT OF EDUCATION
Region III

REGION/DIVISION/DISTRICT:
NAME OF SCHOOL:
SCHOOL ID NO.:

SCHOOL-BASED FEEDING PROGRAM - MILK COMPONENT

LIST OF AUTHORIZED CONSIGNEES (SY 2021-2022)

NAME & DESIGNATION TEL. NO. MOBILE NO. EMAIL ADD SPECIMEN
SIGNATURE
1 (School Head)

2 (School Feeding Coordinator)

3 (School Property Custodian)

SCHOOL INSPECTION TEAM (SY 2021-2022)

NAME & DESIGNATION TEL. NO. MOBILE NO. EMAIL ADD SPECIMEN
SIGNATURE
1

Note: Only authorized consignees are allowed to receive the goods.

SBFP Form 5 (2021)

DEPARTMENT OF EDUCATION
Region III

REGION/DIVISION/DISTRICT:
NAME OF SCHOOL:
SCHOOL ID NO.:

SCHOOL-BASED FEEDING PROGRAM - MILK COMPONENT

LIST OF BENEFICIARIES (SY 2020-2021)

Classification of Students in terms of Milk Tolerance
(Please check one)
Without milk With milk Not allowed by
intolerance and will intolerance but parents to
Name Grade & Section participate in milk willing to participate in milk
feeding participate in milk feeding
feeding
1
2
3
4
5
6
7
8
9
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SBFP Form 5 (2021)

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SBFP Form 5 (2021)

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SBFP Form 5 (2021)

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SBFP Form 5 (2021)

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Prepared by: APPROVED BY:

School Feeding Coordinator School Head

SBFP Form 6 (2021)

DEPARTMENT OF EDUCATION
Region III

REGION/DIVISION/DISTRICT:
NAME OF SCHOOL:
SCHOOL ID NO.:

SCHOOL-BASED FEEDING PROGRAM

NFP DELIVERIES (SY________)

Grade Level Number of Beneficiaries Date No. of Packs Received No. of Packs for Remarks
Delivered Replacement/
New Replacement Total (New + Rejected
Replacement)
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
SPED
TOTAL:

MILK DELIVERIES (SY________)

Grade Level Number of Beneficiaries Date No. of Packs Received No. of Packs for Remarks
Delivered Replacement/
New Replacement Total (New + Rejected
Replacement)
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
SPED
TOTAL:

Prepared by: APPROVED BY:

School Feeding Coordinator School Head

Attachment 2
Document Code:
Quality Form
Revision:
OK sa DepEd - School-Based Feeding Program (SBFP)
Program Terminal Report Form Effectivity date: 01-01-2021

(SBFP Form 7A) BLSS-School Health Division

Region/Division: Period Covered:

School Name & ID:
School Address:
School Telephone Number: Mobile Number:
Fax Number: Email Address:
Total Enrolment: Total No. of T & NTP:

A. ACCOMPLISHMENTS

1. SBFP Coverage: Primary Beneficiaries for Nutritious Food Products

Grade Level All Kinder Severely Wasted Wasted TOTAL

Kinder 0
Grade 1 0
Grade 2 0
Grade 3 0
Grade 4 0
Grade 5 0
Grade 6 0
SPED 0
Multigrade 0
TOTAL 0 0 0 0

2. SBFP Coverage: Secondary Beneficiaries for Nutritious Food Products

Pupils-at-Risk-of-
Grade Level Stunted Indigenous Peoples Indigent Learners TOTAL
Dropping-Out (PARDOs)

Kinder 0
Grade 1 0
Grade 2 0
Grade 3 0
Grade 4 0
Grade 5 0
Grade 6 0
SPED 0
Multigrade 0
TOTAL 0 0 0 0 0
Attachment 2
3. SBFP Coverage: Primary Beneficiaries for Milk

Grade Level All Kinder Severely Wasted Wasted TOTAL

Kinder 0
Grade 1 0
Grade 2 0
Grade 3 0
Grade 4 0
Grade 5 0
Grade 6 0
SPED 0
Multigrade 0
TOTAL 0 0 0 0

4. SBFP Coverage: Secondary Beneficiaries for Milk

Pupils-at-Risk-of-
Grade Level Stunted Dropping-Out (PARDOs) Indigenous Peoples Indigent Learners TOTAL

Kinder 0
Grade 1 0
Grade 2 0
Grade 3 0
Grade 4 0
Grade 5 0
Grade 6 0
SPED 0
Multigrade 0
TOTAL 0 0 0 0 0

5. Type of Food Commodities Distributed to Learners (Check applicable items)

a. Nutritious Food Products
Enutribun
Fortified/Enriched Bread
Fruits
Rootcrops
Vegetables
Nutripacks

b. Milk
Fresh Milk
Sterilized Milk
Commercial Milk
Provided by Partner

6. SBFP Funds (for those with downloaded funds)

Tranches Amount Received from SDO Funds Utilized Percent Utilization
(col 3/2*100%)

Total:
Attachment 2

B. DONATIONS/ RESOURCES GENERATED

(Add Additional Sheets, if needed)

Partner & Type of Donations/Services Provided Quantity (if applicable) Estimated Cost (if applicable)

C. SIGNIFICANT EVENTS OF SBFP, AND OTHER HEALTH AND NUTRITION PROGRAMS/

EXPERIENCES/ GOOD PRACTICES
(Add Additional Sheets, if needed)
What happened? Who were involved? When Outcome: What is/are its important contribution to the
School-Based Feeding Program of the school?

D. LESSONS LEARNED G. SUGGESTIONS TO STRENGTHEN SBFP (Include support

needed from Central, Region, and Division Office that can increase the impact of OK
sa DepEd Program in the schools)

E. PROPOSED PLAN OF ACTION AND RECOMMENDATIONS

F. PHOTOS (Before, During and After)

Prepared by: Noted:

SBFP Coordinator School Head

Date:
SBFP Form 6 (2021)

SBFP Form 12 (2021)

School-Based Feeding Program

QUESTIONNAIRE FOR THE PROGRESS MONITORING AND EVALUATION
(SCHOOL LEVEL)
SY 2021-2022

SCHOOL Date: __________________

DISTRICT

1. Preparation of Data for the Program

· List of beneficiaries
· Nutritional Assessment
SW W N OW O TOTAL
KINDER
GRADE 1
GRADE 2
GRADE 3
GRADE 4
GRADE 5
GRADE 6
SPED
TOTAL

· School Work and Financial Plan _______________________

· Cycle Menu
· Project Procurement Management Plan
2. Release of funds from SDO to School
· Amount released in School
1st tranche _____________________
2nd tranche _____________________
· Date Received _____________________
· No funds Allocated _____________________
3. Orientation of SBFP
· with orientation
· no orientation
4. Partnership with various stakeholders in the School
· NGO
· GO
· LGU
· Foundation
5. Program Management
· Date Started
· Expected no. of days of completion
· Procurement method followed
· Nutrition Education during feeding
· Weighing scale used in school
· Compliance to cycle menu
· Attendance of the beneficiaries
· Parents Involvement
6. Development of Health and Nutrition Values
· Proper handwashing
· Prayer before and after meal
· Good grooming and personal hygiene
7. Complementary Activities
· No. of beneficiaries dewormed
· With functional School Garden
· Waste segregation and composting
· Adherence to food safety
8. Submission of SBFP forms
· with report
· without report
9. Submission of Liquidation Report
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SBFP Form 6 (2021)

· with liquidation ___________________________

· without liquidation ___________________________
10. Issues and concerns
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SUBMITTED BY:

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SCHOOL HEAD

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NUTRITION LEADER

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SCHOOL BAC CHAIRMAN