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Deworming Forms

This document contains a form for tracking student enrollment, deworming status, and medication administration rounds (MARs) at a school. It lists the names, addresses, birthdays, ages, sexes, and deworming statuses of enrolled students. For each MAR, it indicates whether students were dewormed and if they had any adverse drug reactions (ADRs). Totals are provided for numbers of students dewormed in each category. The form is used to monitor school-based deworming programs and ensure students receive recommended treatment.

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marlon novisio
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134 views8 pages

Deworming Forms

This document contains a form for tracking student enrollment, deworming status, and medication administration rounds (MARs) at a school. It lists the names, addresses, birthdays, ages, sexes, and deworming statuses of enrolled students. For each MAR, it indicates whether students were dewormed and if they had any adverse drug reactions (ADRs). Totals are provided for numbers of students dewormed in each category. The form is used to monitor school-based deworming programs and ensure students receive recommended treatment.

Uploaded by

marlon novisio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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DepEd Form 1A.

List of SAC Enrolled Per Class and Deworming Status by MDA Round

School ID: Name of School: Type: 1- Public 2-Private School Year: Grade Level/Section:

Adress of the School: District: Division: Region:


Part 1. List of SAC Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status of
Deworming by
No. Name of SAC Address Birthday Age Sex SE Status First Round of MDA (August'2022) Second Round of MDA (Feb. 2023) School Year
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed / - with ADR, / - dewormed, / - withADR Remarks / - received 2
write date specify Remarks write date specify type doses/year
F-Female Non4Ps X - received only 1
dewormed type dewormed
X - no ADR X - no ADR dose or no
X - not X - not dose/year
(6) (14)
(1) (2) (3) (4) (5) (7) dewormed dewormed (13)
(8) (9) (10) (11)
(12)

1 ANGLO,CHRIZT KAILLER, DE TULAY SILANGAN MARAG07-18-2015 7 M January.2022 X


2 BERATIO,KOBE, VILLANUEV LAYONG MABILOG MARA01-27-2015 7 M / 07-25-22 X
3 BIBON,NATHAN PAUL, MARTULAY SILANGAN MARAG09-02-2014 8 M 08-27-22 X
4 CASAPAO,KHNELL ISAAC, DETULAY SILANGAN MARAG02-20-2015 7 M 10/8/2022 X
5 CASTRONUEVO,LANCE LINDTULAY SILANGAN MARAG11-09-2014 8 M
6 CRUZ,ZILJAN, DE JESUS TULAY SILANGAN MARAG10-21-2014 8 M
7 DEL ROSARIO,DRICH LORRE TULAY SILANGAN MARAG10-31-2014 8 M 08-19-22 X
8 LINEZO,CARL JEMILLE, DELATULAY SILANGAN MARAG10-11-2014 8 M X X
9 MANDASOC,SEAN IVAN, M TULAY SILANGAN MARAG05-01-2014 8 M 08-18-22 X
10 MIRANDA,GABRIEL, TANGALTULAY SILANGAN MARAG10-20-2014 8 M 08-19-22 X
11 PAITON,SIAN JHONES, SOLATULAY SILANGAN MARAG07-08-2015 7 M July.2022 X
1 ANCHUREZ,CYRA ATHENA, TULAY SILANGAN MARAG 1/5/2015 7 F X X
2 BERSABE,XYRICH, - TULAY SILANGAN MARAG12-11-2014 8 F X /
3 CASAUL,ZYDEN CHLOE, DE TULAY SILANGAN MARAG09-07-2015 7 F X X
4 DE LEON,JHAICA, PESCASIO TULAY SILANGAN MARAG06-13-2015 7 F 08-18-22 X
5 DE MESA,QUEEN CELYN, ZI TULAY SILANGAN MARAG11-08-2014 8 F 1/8/2022 X
6 DELA CRUZ,VANNESS, PANI TULAY SILANGAN MARAG06-01-2015 7 F X X
7 DINGLASAN,LENOX MILE, - TULAY SILANGAN MARAG04-30-2015 7 F / X
8 LARA,GINA MARIE, SURBANTULAY SILANGAN MARAG11-23-2013 9 F 08-19-22 X
9 LLEGO,PRECIOUS MIRACLE TULAY SILANGAN MARAG07-25-2015 7 F
10 MOJICA,ELYZA GABRIELLE, TULAY SILANGAN MARAG09-21-2015 7 F 08-26-22 X
11 MOJICA,JHIRACE FAITH, DE TULAY SILANGAN MARAG04-05-2015 7 F 11/8/2022 X
12 RAMOS,OCTAIM KYRA, LEGATULAY SILANGAN MARAG10-22-2014 8 F 08-18-22 X
13 ROSALES,RENZE YZZABEL, TULAY SILANGAN MARAG05-07-2015 7 F 08-21-22 X
14 TANTAN,UNICE, SAMPAG TULAY SILANGAN MARAG07-26-2015 7 F 10/8/2022 X
Part 1. List of SAC Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status of
Deworming by
No. Name of SAC Address Birthday Age Sex SE Status First Round of MDA (August'2022) Second Round of MDA (Feb.'2023) School Year
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed, / - with ADR, / - dewormed, / - with ADR Remarks / - received 2
write date specify Remarks write date specify type doses/year
F-Female Non-4Ps X - received only 1
dewormed type dewormed
X - no ADR X - no ADR dose or no
X - not X - not dose/year
(6) (14)
(1) (2) (3) (4) (5) (7) dewormed (10) dewormed (13)
(8) (9) (11)
(12)

Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No.NHTS- 4Ps No. w/ ADR: No. recvd 2 doses:
F: Dewormed: Dewormed:
NHTS-non4Ps No. recvd 1 or 0
No. NHTS non No. NHTS non dose:
4Ps 4Ps
Dewormed: Dewormed:

Total: Total:
Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No.NHTS- 4Ps No. w/ ADR: No. recvd 2 doses:
F: Dewormed: Dewormed:
NHTS-non4Ps No. recvd 1 or 0
No. NHTS non No. NHTS non dose:
4Ps 4Ps
Dewormed: Dewormed:

Total: Total:

Accomplished by Classroom Adviser:


Noted by Grade Level Chairman:
Date:
DepEd Form 1B. List of Adolescents Enrolled Per Class and Deworming Status by MDA Round

School ID: Name of School: Type: 1- Public 2-Private School Year: Grade Level/Section:

Adress of the School: District: Division: Region:


Part 1. List of Adolescents Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status of
Deworming by
No. Name of Adolescent Address Birthday Age Sex SE Status First Round of MDA (August'2022) Second Round of MDA (Feb.'2023) School Year
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed, / - with ADR, Remarks / -dewormed, / - withADR Remarks / - received 2
write date specify write date specify type doses/year
F-Female Non4Ps X - received only
dewormed type dewormed X - no ADR
X - not X - no ADR 1dose or no
dewormed X - not dose/year
(6) (7)
(1) (2) (3) (4) (5) (10) dewormed (12) (13)
(8) (9) (11) (14)
Part 1. List of Adolescents Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status
ofDeworming
No. Name of Adolescent Address Birthday Age Sex SE Status First Round of MDA (August'2022) Second Round of MDA (February'2023) by SchoolYear
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed, / - with ADR, Remarks / - dewormed, / - with ADR, Remarks / - received 2
write date specify write date specify type doses/year
F-Female Non-4Ps X - received only
dewormed type dewormed X - no ADR
X - not X - no ADR 1 dose or no
dewormed X - not dose/year
(6) (7) (14)
(1) (2) (3) (4) (5) (10) dewormed (12)
(8) (9) (11) (13)

Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No. NHTS-4Ps No. w/ ADR: No. recvd 2
F: Dewormed: Dewormed: doses:
NHTS-
non4Ps No. NHTS non No. NHTS non No. recvd 1 or 0
4Ps Dewormed: 4Ps Dewormed: dose:

Total: Total:
Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No. NHTS-4Ps No. w/ ADR: No. recvd 2
F: Dewormed: Dewormed: doses:
NHTS-
non4Ps No. NHTS non No. NHTS non No. recvd 1 or 0
4Ps Dewormed: 4Ps Dewormed: dose:

Total: Total:

Accomplished by Classroom Adviser:


Noted by Grade Level Chairman:
Date:
School
DepEd Form 2. Consolidation of MDA Coverage of SAC (Kinder to Grade 12) Year: 2022-2023
School
ID: Name of School: Type: 1-Public 2-Private
Address of the
School: District: Division: Cavite Province Region: IV- A

First MDA Round (August' 2022) Second MDA Round (February' 2023) No. Given 2 doses By SY

Grade Total No. Total Number Dewormed No. w/ Total Number Dewormed No. w/ NHTS
adverse adverse NHTS- Remarks
Level Enrolled Remarks Non-
drug drug 4Ps Total (9)
(1) (2) (5) 4Ps
NHTS NHTS reactions NHTS NHTS reactions (8a)
(4) Total (7) (8b)
4Ps Non4Ps Total 4Ps Non4Ps
(3a) (3b) (6a) (6b)
Kinder

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8
Grade 9

Grade
10
Grade
11
Grade
12
SPED
ALS
Total 0 0 0 0 0 0 0 0 0 0 0 0 0
Percent (%):
Column Total
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Divide Row Total
Multiplied by 100
Accomplished by School Clinic Teacher:
Noted by School Principal:
Date Accomplished:

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