Republic of the Philippines

Tarlac City Nutrition Committee

National Nutrition Council

List of 1-4 years old Children given Deworming Tab

Barangay : Dela Paz

City/ Municipality : Tarlac City Province : Tarlac
CHC III Month and Year : _______________

Total Given : ________

Given Deworming
No. Name of Household Name of Child Age in tab Put a Signature
head /mother/caregiver months
January July

Prepared by: ___________________________________ ____________________________

Name and Signature of Barangay Health Worker

Submitted by: ___________________________________ ____________________________

Name and Signature of Barangay Nutrition Scholar

Checked by: ___________________________________ ____________________________

Name and Signature of Midwife