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Deworming Forms
Deworming Forms
List of SAC Enrolled Per Class and Deworming Status by MDA Round
School ID: Name of School: Type: 1- Public 2-Private School Year: Grade Level/Section:
Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No.NHTS- 4Ps No. w/ ADR: No. recvd 2 doses:
F: Dewormed: Dewormed:
NHTS-non4Ps No. recvd 1 or 0
No. NHTS non No. NHTS non dose:
4Ps 4Ps
Dewormed: Dewormed:
Total: Total:
Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No.NHTS- 4Ps No. w/ ADR: No. recvd 2 doses:
F: Dewormed: Dewormed:
NHTS-non4Ps No. recvd 1 or 0
No. NHTS non No. NHTS non dose:
4Ps 4Ps
Dewormed: Dewormed:
Total: Total:
School ID: Name of School: Type: 1- Public 2-Private School Year: Grade Level/Section:
Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No. NHTS-4Ps No. w/ ADR: No. recvd 2
F: Dewormed: Dewormed: doses:
NHTS-
non4Ps No. NHTS non No. NHTS non No. recvd 1 or 0
4Ps Dewormed: 4Ps Dewormed: dose:
Total: Total:
Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No. NHTS-4Ps No. w/ ADR: No. recvd 2
F: Dewormed: Dewormed: doses:
NHTS-
non4Ps No. NHTS non No. NHTS non No. recvd 1 or 0
4Ps Dewormed: 4Ps Dewormed: dose:
Total: Total:
First MDA Round (August' 2022) Second MDA Round (February' 2023) No. Given 2 doses By SY
Grade Total No. Total Number Dewormed No. w/ Total Number Dewormed No. w/ NHTS
adverse adverse NHTS- Remarks
Level Enrolled Remarks Non-
drug drug 4Ps Total (9)
(1) (2) (5) 4Ps
NHTS NHTS reactions NHTS NHTS reactions (8a)
(4) Total (7) (8b)
4Ps Non4Ps Total 4Ps Non4Ps
(3a) (3b) (6a) (6b)
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade
10
Grade
11
Grade
12
SPED
ALS
Total 0 0 0 0 0 0 0 0 0 0 0 0 0
Percent (%):
Column Total
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Divide Row Total
Multiplied by 100
Accomplished by School Clinic Teacher:
Noted by School Principal:
Date Accomplished: