Republic of the Philippines

Department of Education
Region IV - A CALABARZON
CAMFLORA NATIONAL HIGH SCHOOL (ANNEX)
Talisay, San Andres, Quezon

Form 1 - Classroom Level

National School Deworming Month (NSDM) Round 2
June ___, 2017
District: III School ID: 308024
Name of School: Camflora National High School (Annex) Grade/Section: __________

Dewormed Consented to Not Dewormed

Deworming (as
No. Name of Child indicated in
consent form) Refused Non consent Precautionary
4Ps Non-4Ps deworming form returned Measure

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
TOTAL
Accomplished by: NOTED:
_____________________________ ________________________________
 Class Adviser School Deworming Coordinator
Date Accomplished:
_____________________________
08024
n: __________

Adverse Event

__________________
ng Coordinator