STO.

TOMAS INTEGRATED HIGH SCHOOL DEWORMING MONTH FOR THE SCHOOL YEAR 2020-2021
ANNEX C: Form 4c MODIFIED District Level Reporting Form for the Month of July

No. of Enrolled Children CHILDREN DEWORMED

Consented to deworming
Refused to deworming as No consent form
School Grade Level as indicated to consent indicated to consent form returned
form
4P's Non 4P's TOTAL 4P'S &
Male Female
NON 4P'S
Male Female Male Female
Kinder 0
Grade 1 0
Grade 2 0
Grade 3 0
Grade 4 0
Grade 5 0
Grade 6 0
SPED 0
Grade 7 131 115 0 8 10 11 29 29 217 0
Grade 8 161 130 7 4 10 11 32 32 259 0
Grade 9 133 146 4 8 7 11 30 30 249 0
Grade 10 125 128 1 2 1 0 4 4 249 0
Grade 11 113 87 3 3 0 0 6 6 194 0
Grade 12 110 87 0 1 0 0 1 1 196 0
ALS 0
TOTAL 773 693 15 26 28 33 102 102 1364 0

Prepared by: Approved by:

 Precautionary measure
seriously ill with abdominal
Adverse event reported % dewormed (Total
pain, diarrhea, who has (type and no.) dewormed/ enrolled)
previous hypersensitivity with
deworming drug

0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
None to report 0 22.14
None to report 0 19.88
None to report 0 22.56
None to report 0 3.20
None to report 0 5.31
None to report 0 0.91
0 #DIV/0!
0 0 13.20