Attachment 2

Document Code:
Quality Form
Revision:
OK sa DepEd - School-Based Feeding Program (SBFP)
Program Terminal Report Form Effectivity date: 01-1-2021

(SBFP PTR - Form C) BLSS-School Health Division

Region/Division: Period Covered:

Office Address:
Office Telephone Number: Mobile Number:
Fax Number: Email Address:
Number of Schools in the Region: Elementary Enrolment:
Secondary Enrolment:
TOTAL:
A. ACCOMPLISHMENTS

1. SBFP Coverage: Total Beneficiaries for Nutritious Food Products

Pupils-at-Risk-
Severely Indigenous Indigent
SDOs All Kinder Wasted Stunted of-Dropping- TOTAL
Wasted Peoples Learners
Out (PARDOs)
0
0
0
0
0
0
0
0
0
TOTAL 0 0 0 0 0 0 0 0

2. SBFP Coverage: Total Beneficiaries for Milk sourced from NDA/PCC

Severely Pupils-at-Risk- Indigenous Indigent
SDOs All Kinder Wasted Stunted of-Dropping- TOTAL
Wasted Peoples Learners
Out (PARDOs)
0
0
0
0
0
0
0
0
0
TOTAL 0 0 0 0 0 0 0 0

3. SBFP Coverage: Total Beneficiaries for Milk sourced from Commercial Sources
Severely Pupils-at-Risk- Indigenous Indigent
SDOs All Kinder Wasted Stunted of-Dropping- TOTAL
Wasted Peoples Learners
Out (PARDOs)
0
0
0
0
0
0
0
0
0

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Attachment 2
TOTAL 0 0 0 0 0 0 0 0

4. SBFP Coverage: Total Beneficiaries for Milk Donated by Partners

Pupils-at-Risk-
SDOs All Kinder Severely Wasted Stunted of-Dropping- Indigenous Indigent TOTAL
Wasted Out (PARDOs) Peoples Learners
0
0
0
0
0
0
0
0
0
TOTAL 0 0 0 0 0 0 0 0

5. SBFP Coverage: Grand Total Beneficiaries for Milk (All sources)

Severely Pupils-at-Risk- Indigenous Indigent
SDOs All Kinder Wasted Wasted Stunted of-Dropping- Peoples Learners TOTAL
Out (PARDOs)
0
0
0
0
0
0
0
0
0
TOTAL 0 0 0 0 0 0 0 0

6. 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

7. SBFP Funds (for those with downloaded funds)

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

NFP
Milk
PSF
Additional Funds
Total:

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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 Schools Division Superintendent

Date:

OPLAN KALUSUGAN SA DEPED: Accomplishment Report... 3 of 9

Attachment 2
Document Code:
Quality Form
Revision:
OK sa DepEd - School-Based Feeding Program (SBFP)
Program Terminal Report Form Effectivity date: 01-1-2021

(SBFP PTR - Form B) BLSS-School Health Division

Region/Division: Period Covered:

Office Address:
Office Telephone Number: Mobile Number:
Fax Number: Email Address:
Number of Schools in the Schools Division: Elementary Enrolment:
Secondary Enrolment:
TOTAL:
A. ACCOMPLISHMENTS

1. SBFP Coverage: Total Beneficiaries for Nutritious Food Products

Pupils-at-Risk-
Severely Indigenous Indigent
Grade Level All Kinder Wasted Stunted of-Dropping- TOTAL
Wasted Peoples Learners
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 0 0 0

2. SBFP Coverage: Total Beneficiaries for Milk sourced from NDA/PCC

Severely Pupils-at-Risk- Indigenous Indigent
Grade Level All Kinder Wasted Stunted of-Dropping- TOTAL
Wasted Peoples Learners
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 0 0 0

3. SBFP Coverage: Total Beneficiaries for Milk sourced from Commercial Sources
Severely Pupils-at-Risk- Indigenous Indigent
Grade Level All Kinder Wasted Stunted of-Dropping- TOTAL
Wasted Peoples Learners
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

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Attachment 2
TOTAL 0 0 0 0 0 0 0 0

4. SBFP Coverage: Total Beneficiaries for Milk Donated by Partners

Pupils-at-Risk-
Grade Level All Kinder Severely Wasted Stunted of-Dropping- Indigenous Indigent TOTAL
Wasted Out (PARDOs) Peoples Learners
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 0 0 0

5. SBFP Coverage: Grand Total Beneficiaries for Milk (All sources)

Severely Pupils-at-Risk- Indigenous Indigent
Grade Level All Kinder Wasted Wasted Stunted of-Dropping- Peoples Learners TOTAL
Out (PARDOs)
Kinder 32 32
Grade 1 8 8
Grade 2 4 4
Grade 3 4 4
Grade 4 4 4
Grade 5 2 2
Grade 6 1 1
SPED 0
Multigrade 0
TOTAL 32 0 23 0 0 0 0 55

6. 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

7. SBFP Funds (for those with downloaded funds)

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

Total:

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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 Schools Division Superintendent

Date:

OPLAN KALUSUGAN SA DEPED: Accomplishment Report... 6 of 9

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 PTR - Form A) BLSS-School Health Division

Region/Division: East Nasipit District Period Covered: 2020-2021

School Name & ID: 131494 - Cubi-Cubi Elementary School
School Address: Central II, Barangay Cubi-Cubi, Nasipit, Agusan del Norte
School Telephone Number: None Mobile Number: 9051292285
Fax Number: None Email Address: herminia.vicada001@deped.gov.ph
Total Enrolment: 285 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 30 30
Grade 1 8 2 6 8
Grade 2 4 0 4 4
Grade 3 4 1 3 4
Grade 4 4 0 5 5
Grade 5 2 0 2 2
Grade 6 1 1 1 2
SPED 0
Multigrade 0
TOTAL 55 4 21 55

2. SBFP Coverage: Secondary Beneficiaries for Nutritious Food Products

Pupils-at-Risk-of-
Grade Level Stunted Dropping-Out Indigenous Peoples Indigent Learners TOTAL
(PARDOs)
Kinder 6 0 0 4 10
Grade 1 5 0 0 2 7
Grade 2 6 1 0 12 19
Grade 3 1 2 0 9 12
Grade 4 4 0 0 9 13
Grade 5 3 1 0 8 12
Grade 6 2 1 0 5 8
SPED 0 0 0 0 0
Multigrade 0 0 0 0 0
TOTAL 27 5 0 49 81

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Attachment 2

3. SBFP Coverage: Primary Beneficiaries for Milk

Grade Level All Kinder Severely Wasted Wasted TOTAL

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

4. SBFP Coverage: Secondary Beneficiaries for Milk

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

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

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

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:

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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:

HERMINIA P. VICADA LILIBETH B. BELIOTA

SBFP Coordinator School Head
Date:

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