Quality Form Document Code:

OK sa DepEd - School-Based Feeding Program (SBFP) Revision:

Program Terminal Report Form Effectivity date: 01-01-

(SBFP PTR - Form A) 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: Total Beneficiaries for Nutritious Food Products
Grade Level All Kinder Severely Wasted Stunted
Pupils-at-Risk-of-
Dropping-Out
Indigenous Indigent Last Mile Schools
TOTAL
Wasted (PARDOs) Peoples Learners (with less than 100)

Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
SPED
Multigrade
TOTAL
2. SBFP Coverage: Total Beneficiaries for Milk sourced from NDA/PCC
Severely Pupils-at-Risk-of- Indigenous Indigent Last Mile Schools
Grade Level All Kinder Wasted Stunted Dropping-Out TOTAL
Wasted (PARDOs) Peoples Learners (with less than 100)

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

3. SBFP Coverage: Total Beneficiaries for Milk sourced from Commercial Sources
Severely Pupils-at-Risk-of- Indigenous Indigent Last Mile Schools
Grade Level All Kinder Wasted Wasted Stunted Dropping-Out
Peoples Learners (with less than 100) TOTAL
(PARDOs)

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

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

Grade Level All Kinder Severely Wasted Stunted
Pupils-at-Risk-of-
Dropping-Out
Indigenous Indigent Last Mile Schools
TOTAL
Wasted (PARDOs) Peoples Learners (with less than 100)
 Grade Level All Kinder Severely Wasted Stunted
Pupils-at-Risk-of-
Dropping-Out
Indigenous Indigent Last Mile Schools
TOTAL
Wasted (PARDOs) Peoples Learners (with less than 100)

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

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

Grade Level All Kinder Severely Wasted Stunted
Pupils-at-Risk-of-
Dropping-Out
Indigenous Indigent Last Mile Schools
TOTAL
Wasted (PARDOs) Peoples Learners (with less than 100)

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

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

a. Nutritious Food Products (NFP)
Enutribun
Milky Bun
 Fortified/Enriched Bread
Fruits / Fruit Products
Rootcrops
Vegetables
Nutripacks
Cereals/Grains

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

7. SBFP Funds (for those with downloaded funds)

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

Nutritious Food Product (30 days)

Milk Feeding (16 days)
Additional (If any)
Total:

B. DONATIONS/ RESOURCES GENERATED

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

G. SUGGESTIONS TO STRENGTHEN SBFP (Include support needed

D. LESSONS LEARNED 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. NUTRITIONAL STATUS
BEFORE FEEDING AFTER FEEDING

GRADE NO.
LEVEL OF SW W TOTAL SW % W % N % OW % O % TOTAL
BENS

KINDER
 GRADE 1
GRADE 2
GRADE 3
GRADE 4
GRADE 5
GRADE 6
SPED
IPED
INDIGENT
LEARNERS
MULTIGRA
DE
PARDOs

TOTAL

F. PHOTOS (Before, During and After)

Prepared by: Noted:

SBFP Coordinator School Head

Date: Date: