Form 1 - Classroom Level

SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/2ND ROUND) ELEMENTARY SY2022-2023

DIVISION:

DISTRICT :

SCHOOL:

GRADE LEVEL/SECTION:
DATE ACCOMPLISHED:

CONSENT No. of Children Dewormed Remarks

NAME OF STUDENT
YES NO MALE FEMALE

TOTAL

Noted by: Prepared by:

Health/Nutrition Leader Class Adviser

SDO-QF-SGOD-HNU-020
Form 2- School Level

SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/2ND ROUND) ELEMENTARY SY 2022-2023

DISTRICT :
NAME OF SCHOOL :
DATE ACCOMPLISHED:

ENROLMENT TOTAL NO. GIVEN (ALBENDAZOLE/MEBENDAZOLE) % OF ACCOMPLISHMENT

GRADE LEVEL

MALE FEMALE TOTAL MALE FEMALE TOTAL

KINDER

GRADE 1

GRADE 2

GRADE 3

GRADE 4

GRADE 5

GRADE 6

SPED

TOTAL

Noted by: Prepared by:

School Head Health Leader/Nutrition Leader

Form 3 - District Level

SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/2ND ROUND) ELEMENTARY SY 2022-2023

DIVISION:

DISTRICT :
DATE ACCOMPLISHED:

ENROLMENT TOTAL NUMBER OF CHILDREN DEWORMED Remarks

SCHOOL ID NAME OF SCHOOL

MALE FEMALE TOTAL MALE FEMALE TOTAL

TOTAL

Noted by: Prepared by:

District Schools Supervisor Health/Nutrition Coordinator

Form 1 - Classroom Level

SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/2ND ROUND) SECONDARY

DIVISION:

CLUSTER :

SCHOOL:

GRADE LEVEL/SECTION:
DATE ACCOMPLISHED:

CONSENT No. of Children Dewormed Remarks

NAME OF STUDENT
YES NO MALE FEMALE

TOTAL

Noted by: Prepared by:

Health/Nutrition Leader Class Adviser

Form 2- School Level

SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/2ND ROUND) SY 2022-2023

CLUSTER:
NAME OF SCHOOL :
DATE ACCOMPLISHED:

ENROLMENT TOTAL NO. GIVEN (ALBENDAZOLE/MEBENDAZOLE) % OF ACCOMPLISHMENT

GRADE LEVEL

MALE FEMALE TOTAL MALE FEMALE TOTAL

GRADE 7

GRADE 8

GRADE 9

GRADE 10

GRADE 11

GRADE 12

TOTAL

Noted by: Prepared by:

Principal Health Leader/Nutrition Leader

SDO-QF-SGOD-HNU-021
Annex III

INTEGRATED HELMINTH CONTROL PROGRAM

Adverse Events Following Deworming/Severe Adverse Events

REPORTING FORM

To be filled in by the Physician/Midwife/Barangay Health Worker/Teacher or Parents as needed

during every mass deworming campaign

Region: ___________ Province: _____________________ Municipality: ______________________

Service outlet: (Please check and indicate name of RHU, School, Daycare

Barangay Health Station/RHU: _______________________________

School: _______________________________
Day Care center: _______________________

Day of deworming: ________________________ Time of Deworming: ________________________

Chief complaint and

Name of Patient Age Complete Address time of onset of signs Action Taken Remarks
and symptoms

Accomplished by: __________________________________

(Print name and signature)
Date: __________________________
Form 4 - Division Level

DIVISION LEVEL SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/2ND ROUND) SY 2022-2023

Date:

ENROLMENT TOTAL NO. GIVEN (ALBENDAZOLE/MEBENDAZOLE)

GRADE LEVEL % OF ACCOMPLISHMENT

MALE FEMALE TOTAL MALE FEMALE TOTAL

KINDER

GRADE 1

GRADE 2

GRADE 3

GRADE 4

GRADE 5

GRADE 6

SPED

TOTAL

GRADE 7

GRADE 8

GRADE 9

GRADE 10

GRADE 11

GRADE 12

TOTAL

GRAND TOTAL

Noted by: Prepared by:

ROBERTA T. ALONZO
PONCIANA C. LENON Nurse II
Division Point Person
CARLA MARIE RHYAN M. GAMBOA
GENER B. APOSTOL Nurse II
Medical Officer III
ROMEO I. CAPULONG
Reviewed by: Nurse II

ARCELI S. LOPEZ
Chief - SGOD

Recommending Approval:

SHIRLEY B. ZIPAGAN, PhD., CESO VI MELISSA S. SANCHEZ, PhD., CESE

Asst. Schools Division Superintendent Asst. Schools Division Superintendent

Approved by:

Engr. EDGARD C. DOMINGO, PhD., CESO V

Schools Division Superintendent

SDO-QF-SGOD-HNU-022
Department of Education
Bureau of Learner Support Services
SCHOOL HEALTH DIVISION OF PAMPANGA
Highschool Blvd., Brgy Lourdes, City of San Fernando, Pampanga, 2000
Website: wwww.depedpampanga.com | Email: [email protected]
Tel.: (045) 435-7404 | Fax: (045) 043-2728

SCHOOL BASED DEWORMING ACCOMPLISHMENT REPORT (1ST ROUND/ 2ND ROUND) S.Y. ______________

CLUSTER/DISTRICT :
NUMBER OF SCHOOL :
DATE ACCOMPLISHED:

TOTAL NO. GIVEN

GRADE LEVEL ENROLMENT % OF ACCOMPLISHMENT
(ALBENDAZOLE/MEBENDAZOLE)

KINDER

GRADE 1

GRADE 2

GRADE 3

GRADE 4

GRADE 5

GRADE 6

SPED

TOTAL

GRADE 7

GRADE 8

GRADE 9

GRADE 10

GRADE 11

GRADE 12

TOTAL

GRAND TOTAL

Noted by: Prepared by:

_______________________________ _______________________________
PONCIANA C. LENON ROBERTA T. ALONZO
Division Point Person Nurse II

Reviewed by:
CARLA MARIE RHYAN D. MANGUNE
______________________________ Nurse II
GENER B. APOSTOL, M.D.
Medical Officer III ____________________________
ROMEO I CAPULONG
Nurse II