Republic of the Philippines

Department of Education
Region IV - A CALABARZON

Form 1 - Classroom Level

National School Deworming Month (NSDM) Round 1

July 2017

District: _____________________________
Name of School:_________________________________ School ID: _____________________
Enrolment: _______________________________ Grade /Section: __________________

Dewormed Consented to Not Dewormed

Deworming
No. Name of Child (as indicated in Refused No consent Precautionary
4Ps Non - 4Ps
consent form) 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: N O T E D:
___________________________ ________________________________
Class Adviser School Deworming Coordinator
Date Accomplished: ___________
______________
_______________

Adverse Event

________________
ming Coordinator
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
Form 2 - School Level (Elementary)
National School Deworming Month (NSDM) Round __
_____________ _______
Month Year
District / Name of School:_____________________________________________________________
No. of Children Dewormed No. of Children NOT Dewormed
Consented to Precautionary measure
Refused Adverse event % Dewormed
Deworming (as No consent (Seriously ill, with abdominal pain,
Grade Enrolment indicated in Deworming (as reported (yes (total dewormed /
TOTAL 4Ps form diarrhea, has previous sensitivity with or no) enrollment)
4Ps Non-4Ps consent form) indicated in
& Non-4Ps returned deworming drug
consent form)
"Annex B" MDAP Guide #1 page 14
Kindergarten 0 0 0 #DIV/0!
Grade 1 0 0 0 #DIV/0!
Grade 2 0 0 0 #DIV/0!
Grade 3 0 0 0 #DIV/0!
Grade 4 0 0 0 #DIV/0!
Grade 5 0 0 0 #DIV/0!
Grade 6 0 0 0 #DIV/0!
TOTAL
(1-6) 0 0 0 0 0 0 #DIV/0!
SPED 0 0 0 #DIV/0!
Grand
Total
0 0 0 0 0 0 #DIV/0!
Accomplished by: N O T E D:
____________________________ _________________________________________
Deworming Coordinator School Nurse School Head
Date Accomplished: __________________

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region IV-A CALABARZON
DIVISION OF RIZAL
Form 2 - School Level (Secondary)
National School Deworming Month (NSDM) Round __
_____________ _______
Month Year
District / Name of School:_____________________________________________________________

No. of Children Dewormed No. of Children NOT Dewormed

Consented to Refused Precautionary measure ( Seriously ill, Adverse event % Dewormed
Deworming (as No consent
Grade Enrolment TOTAL 4Ps deworming (as with abdominal pain, diarrhea, has reported (yes (total dewormed /
4Ps Non-4Ps indicated in form
& Non-4Ps indicated in the previous sensitivity with deworming or no) enrollment)
consent form) returned
consent form) drug)
Grade 7 0 0 0 #DIV/0!
Grade 8 0 0 0 #DIV/0!
Grade 9 0 0 0 #DIV/0!
Grade 10 0 0 0 #DIV/0!
TOTAL
(7-10) 0 0 0 0 0 0 #DIV/0!
Grade 11 0 0 0 #DIV/0!
Grade 12 0 0 0 #DIV/0!
TOTAL
(11-12) 0 0 0 0 0 0 #DIV/0!
SPED 0 0 0 #DIV/0!
ALS 0 0 0 #DIV/0!
Grand
Total
0 0 0 0 0 0 #DIV/0!
Accomplished by: N O T E D:

_____________________ ______________________________
Deworming Coordinator School Nurse School Head
Date Accomplished: __________________
___