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Deworming Forms Form 1 2

This document contains forms for recording data from the National School Deworming Month (NSDM) program in the Philippines. Form 1 is for classroom-level data and collects information on enrolled students, whether they were dewormed, if consent was provided, and any precautions. Form 2 collects school-level data by grade, including numbers of students dewormed, not dewormed, and reasons for not being dewormed. It also calculates the percentage of students dewormed for each grade. The forms are from the Department of Education in Region IV-A and are meant to monitor the deworming program in July 2017.

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John Daniel Paulino Gumban
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233 views6 pages

Deworming Forms Form 1 2

This document contains forms for recording data from the National School Deworming Month (NSDM) program in the Philippines. Form 1 is for classroom-level data and collects information on enrolled students, whether they were dewormed, if consent was provided, and any precautions. Form 2 collects school-level data by grade, including numbers of students dewormed, not dewormed, and reasons for not being dewormed. It also calculates the percentage of students dewormed for each grade. The forms are from the Department of Education in Region IV-A and are meant to monitor the deworming program in July 2017.

Uploaded by

John Daniel Paulino Gumban
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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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: __________________
___

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