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National School Deworming Day June 27,2016

ANNEX C: Form 1 MODIFIED deworming checklist


Laguna
Santa Rosa City
1st
Santa Rosa Elementary School Central III (Special Science Elementary School)

Province
Division
District
Name of School
School Address
Total Enrolment
Grade Level and
Section

Grade VI - SSES

Number Enrolled

Name of Child

with consent

dewormed (June 1-July 29)

4P's
1 Abad, Angelo P.
2 Baadera, Mico Emison C.
3 Beato, Xienweiss M.
4 Capistrano, Jhon Lester T.
5 De Guzman, Jared Grant L.
6 Dichoso, Ezekiel A.
7 Fajutagana, Rain Paul M.
8 Latumbo, Jenkenrick C.
9 Manalansan, Aaron Miguel C.
10 Manguerra, Marius M.
11 Mujeco, Red Yuan Kenjie O.
12 Ricafort, Godwin Miles G.
13 Roldan, Brandon James L.
14 Trianes, Johann Carlo A.
15 Anas, Andrielle D.
16 Barroga, Chienna Reian S.
17 Beato, Jeian S.
18 Briz, Princess Trisha Joy C.
19 Castrodes, Phoemela Denise B.
20 Clacio, Rocelle V.
21 Dela Cruz, Marie Beatrice N.
22 Diestro, Ma. Kristine M.
23 Jurilla, Neah Venice B.
24 Llamas, Angel Cassandra
25 Lumbris, Zane Gabrielle B.
26 Mondiguing, Syllen Ann A.

1
1
1
1

1
1
1
1

1
1
1
1

1
1
1
1
1

27 Nuarin, Ghislaine S.
28 Olarte, Penelope P.
29 Palacios, Mikaela A.
30 Perez, Ishiah Jarah S.
31 Roldan, Dylene Jane L.
32 Servo, Athena M.
33 Solomon, Lea Angela D.
34 Tumanan, Nicole Kate M.
35 Tumilba, Grace Hope R.
Class Adviser
(Name and
Signature)

MERNIE GRACE F. DIONESIO

Date Accomplished

22-Jun-16

1
1

Elementary School)

Remarks for not being dewormed

Ineligible
(dewormed
before June
1)

wormed (June 1-July 29)

Refused
deworming

non-4P's
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

1
1
1
1
1

1
1

1
1
1
1
1
1

1
1
1
1
1
1
1
1
1
1

1
1
1
1
1
1

Precautionary Measure
(seriously ill, with
deferred
abdominal pain, diarrhea,
due to
who has previous
prevalence
hypersensitivity with
survey
deworming drug ( annex B
MDAP Guide #1 page 14)

1
1
1
1
1
1
1
1
Grade Level
Advisor (Name
and Signature)

1
1

1
1
1
1

1
1

1
1

MERNIE GRACE F. DIONESIO

National School Deworming Day July 29, 2015


ANNEX C: Form 1 MODIFIED deworming checklist
Laguna
Santa Rosa City
1st
Santa Rosa Elementary School Central III (Special Science Elementary School)

Province
Division
District
Name of School
School Address
Total Enrolment
Grade Level and
Section

Grade - 1 Camia

Number Enrolled

Name of Child

with consent

dewormed (June 1-July 29)

4P's
1 Algoso, Clark John G.
2 Alojado, Ronielle Joseph V.
3 Amihan, Jhaiden Josh Morana
4 Cagaanan, Prince Jerald D.G
5 Cay, Jerry Jr. B.
6 De Leon, Zan Kelly Yanzhie Jr. B.
7 Diaz, Ashlei Gean N.
8 Dimayuga, Kenneth B.
9 Endozo, Lynderson Ischyron D.
10 Fernandez, JhonYuri O.
11 Grimpluna, Matt Gerald E.
12 Gusi, Robin William C.
13 Guevarra, Rowell Jr. C.
14 Layosa, Jason D.
15 Lingcod, Mickenzie Joshua J
16 Lovendencio, John Carlo M.
17 Manlapit, Josh Perez
18 Marudo, Nathan B.
19 Medrano, Gabriel Villa
20 Mondejar, John David L.
21 Necesito, Rex Justine A.
22 Orana, Arnold C.
23 Otivar, Mar Steven C.
24 Panlingbatan, Bien Jairus B.
25 Saul, Rheian Claud P.
26 Talion, John Vincent N.

1
1

1
1

27 An, Angelica May H.


28 Aunario, Michelle Jaeda D.V
29 Bartolazo, Jamaica Keith N.
30 Burinaga, Jasmen G.
31 De la Cruz, Marjanah D.
32 Embodo, Katrina Mae D
33 Fuentes, Ceana Casey R.
34 Geroy, Olin Riona O.
35 Gomez, Ma. Ysabelle T.
36 Igonia, Rhian C.
37 Inofre, Shane Ann L.
38 Jimenea, Thrishia L.
39 Ramos, Audrey P.
40 Salandanan, Kriselle C.
40
Accomplished by:
Class Adviser
(Name and
Signature)

LUCENA M. VALE

Date Accomplished

31-Jul-15

1
1
1
1

12

Elementary School)

Remarks for not being dewormed

wormed (June 1-July 29)

Ineligible
(dewormed
before June
1)

Refused
deworming

1
1
1
1
1

1
1
1
1
1

1
1

1
1

1
1

1
1

1
1
1
1
1
1
1
1

1
1
1
1
1
1
1
1

1
1

1
1

non-4P's

1
1

1
1

Precautionary Measure
(seriously ill, with
deferred
abdominal pain, diarrhea,
due to
who has previous
prevalence
hypersensitivity with
survey
deworming drug ( annex B
MDAP Guide #1 page 14)

1
1
1

1
1

1
1
1
1

1
1
1
1

1
1
28

1
1
28

1
1
1
1

12
Noted by
Grade Level
Advisor (Name
and Signature)

LUCENA M. VALE

National School Deworming Day July 29, 2015


ANNEX C: Form 2 MODIFIED School Level Reporting Form
Province
Division
District
Name of School
School Address
Total Enrolment

e.g.Pinagbuhatan Elementary School

children Dewormed

Grade Level

Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
TOTAL
Accomplished by:
School Principal
(Name and
Signature)
Date Accomplished

No. of Enrolled Children

with consent

12

12

12

12

4 P's

Remarks for not being dewormed


children Dewormed
Ineligible
(dewormed
before June
1)

non 4 P's

Refused
deworming

Precautionary Measure
(seriously ill, with
deferred
abdominal pain, diarrhea,
due to
who has previous
prevalence
hypersensitivity with
survey
deworming drug ( annex B
MDAP Guide #1 page 14)

12

28

28

12

28

28

Noted by
District
Supervisor (Name
and Signature)

National School Deworming Day July 29, 2015


ANNEX C: Form 3 MODIFIED DIVISION Level Reporting Form
Region
Province
Division
children Dewormed

Name of School

TOTAL
Accomplished by:
Division Point
Person (Name and
Signature)
Date Accomplished

No. of Enrolled Children

with consent

12

12

12

12

4 P's

Remarks for not being dewormed


children Dewormed
Ineligible
(dewormed
before June
1)

non 4 P's

Refused
deworming

Precautionary Measure
(seriously ill, with
deferred
abdominal pain, diarrhea,
due to
who has previous
prevalence
hypersensitivity with
survey
deworming drug ( annex B
MDAP Guide #1 page 14)

12

28

28

12

28

28

Noted by
Schools Division
Superintendent
(Name and
Signature)

National School Deworming Day July 29, 2015


ANNEX C: Form 4b MODIFIED REgional Level Reporting Form
Region
Province
Division

children Dewormed
Division

No. of Enrolled Children

with consent

4 P's
Rizal
TOTAL
Accomplished by:
Division Point
Person (Name and
Signature)
Date Accomplished

12
12

12
12

Remarks for not being dewormed

children Dewormed

Ineligible
(dewormed
before June
1)

Refused
deworming

non 4'Ps
12
12
Noted by
Schools Division
Superintendent
(Name and
Signature)
Date
Accomplished

28
28

28
28

Precautionary Measure
(seriously ill, with
deferred
abdominal pain, diarrhea,
due to
who has previous
prevalence
hypersensitivity with
survey
deworming drug ( annex B
MDAP Guide #1 page 14)

0
0

0
0

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