SBFP Form 1

Department of Education
Region __I_

Master List Beneficiaries for School-Based Feeding Program (SBFP)

Division/Province: ____________ LA UNION Name of Principal : _____________ MARIJOE M. OPENANO

City/ Municipality/Barangay : ___ ARINGAY/ PANGAO-AOAN WEST Name of Feeding Focal Person : __ BLANCA N. DOMONDON
Name of School / School District : PANGAO-AOAN WEST ELEMENTARY SCHOOL

Beneficiary
Date of Participation of SBFP in
Weighing / Age in Weight Height BMI for 6 Nutritional in 4Ps
Date of Birth
No. Name Grade Sex Measuring Years / y.o. and Name of Parents Previous
(MM/DD/YYYY)
(MM/DD/YY Months (Kg) (cm)
above Status (NS) (yes or Years (yes or
YY) no) no)

1 Mark Allen T. Ramirez Kinder M 10/1/2011 6/8/2017 5.8 13 104 12 Wasted No Mina Ramirez No
2 John Raven A. Paneda Kinder M 5/30/2012 6/8/2017 5.7 14 94 12.5 Wasted No Eva Paneda No
3 Jerwin F. Ramirez Kinder M 11/6/2011 6/8/2017 5.7 13 104 12.03 Wasted No Jerome Ramirez No
4 Ivan Troy F. Cagujas Kinder M 9/16/2011 6/8/2017 5.6 13 101 12.7 Wasted Yes Imelda Cagujas No
5 Jan Jan N. Frigillana Kinder M 7/27/2012 6/8/2017 4.11 16 103 12.2 Wasted No Juan Frigillana No
6 Reyniel M. Ayunar Kinder M 11/6/2011 6/8/2017 5.7 14 109 11.8 Wasted No Anamie Ayunar No
7 Cristopher M. Neverida Kinder M 7/6/2011 6/8/2017 4.11 13 101 12.7 Wasted No Cristopher Neverida No
8 Wyndel M. Nieva Kinder M 8/9/2012 6/8/2017 4.1 13 102 12.5 Wasted No Rachel Nieva No
9 Jemuel B. Mangaoang Kinder M 7/20/2012 6/8/2017 4.11 11 94 12.5 Wasted No Jocylen Mangaoang No
10 Khristine R. Cagujas Kinder F 3/6/2012 6/8/2017 5.3 13 103 12.2 Wasted No Cherry Ann Cagijas No
11 Kelvin F. Basallo I M 1/24/2011 6/8/2017 6.5 15 123 12.19 Wasted No Belen Basallo Yes
12 Aljohn B. Mangaoang I M 7/14/2010 6/8/2017 6.11 15 118 12.71 Wasted Yes Jocelyn Mangaoang Yes
13 Mark Renniel C. Neverida I M 8/15/2011 6/8/2017 7 13 104 12.5 Wasted No Marites Neverida No
14 Ayesha Mae R. Mangaoang I F 1/30/2011 6/8/2017 6.5 15 121 12.39 Wasted No Michael Mangaoang No
15 Xyriel P. Munoz I F 6/5/2011 6/8/2017 6 12 106 11.32 Wasted Yes Marivic Munoz Yes
Prepared by:

_____BLANCA N. DOMONDON
Feeding Focal Person
Note: This form shall be prepared by the school, to be compiled by the DO, and for final compilation by the RO, for submission to DepEd-HNC
SBFP Form 2
Department of Education
Region __I_

SCHOOL-BASED FEEDING PROGRAM (SBFP) LIST OF SCHOOLS

Division/Province: ____________ LA UNION

School District/City/ Municipality ARINGAY

Name of District
Name of Schools BEIS ID No. School Address Name of Barangay Supervisors/ Contact Number
School Principal or OICs

PANGAO-AOAN WEST ELEM. 151004 ARINGAY, LA UNION PANGAO-AOAN WEST MARIJOE M. OPENANO 9088634313

Prepared by: Noted by:

BLANCA N. DOMONDON MARIJOE M. OPENANO

SBFP DepED Focal Unit Chief
Note: This form shall be prepared by the DO, for final consolidation by the RO, for submission to DSWD-FO, copy furnished DepEd-HNC
 Total
Beneficiaries

50

M. OPENANO
nit Chief
SBFP Form 3
Department of Education
Region __I_

SCHOOL-BASED FEEDING PROGRAM (SBFP) SUMMARY OF BENEFICIARIES & START OF FEEDING

Division/Province: ____________ LA UNION__________________________
City/ Municipality/Barangay : __ ARINGAY/ PANGAO-AOAN WEST
Name of School / School District PANGAO-AOAN WEST ELEMENTARY SCHOOL/ ARINGAY

Date of Start of Feeding: __________________________

Nutritional Status at Start of Feeding

Number of Undernourished School
Children by Grade Level No. of No. of Pupils who
Severely No. of Total No. of 4 Ps are beneficiaries in
Wasted Wasted Beneficiaries Beneficiaries previous years Remarks

1. Kinder 0 10 10 1 0

2. Grade I 0 5 5 2 3

3. Grade II 0 7 7 2 6

4. Grade III 1 6 7 5 5

5. Grade IV 0 7 7 3 7

6. Grade V 0 5 5 2 3

7. Grade VI 0 9 9 6 5

Total 1 49 50 21 29

Prepared by:

___BLANCA N. DOMONDON__________________________
SBFP DepEd Focal

Note: This form shall be prepared by the school, to be compiled by the DO, and for final compilation by the RO, for submission to DepEd-HNC
 SBFP Form 4
SCHOOL-BASED FEEDING PROGRAM
RECORD OF DAILY FEEDING

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________

ACTUAL FEEDING
PRE FEEDING
4Ps
NAME OF PUPIL Beneficiary Beneficiary Nutritional Status Deworming
(y or n) of Previous Ht Wt Date
SBFP
Age Birth Sex ( ) or Date
NS
(y or n) Date cm kg Taken (X) Taken 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
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
TOTAL:
Prepared by:
LEGEND
____________________________ A. Nutritional Status
B. Deworming D. Actual Feeding
Feeding Teacher / School Nurse For 6-19 y.o For below 6 y.o
SW - Severely wasted SU - Severely underweight ( x ) - not dewormed ( ) - Present, served
W - Wasted U - Underweight ( ) - dewormed ( A ) - Absent, not served
N - Normal N - Normal ( ) - Present, served twice
Ow - Overwieght Ow - Overwieght
O - Obese

Page 7
Note: This form shall be prepared by the school to be consolidated using SBFP Form 5

Page 8
 SBFP Form 4

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________

ACTUAL FEEDING

NAME OF PUPIL

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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
TOTAL:

D. Actual Feeding

( ) - Present, served
( A ) - Absent, not served
( ) - Present, served twice

page 2
 SBFP Form 4

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________

ACTUAL FEEDING

NAME OF PUPIL

61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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
TOTAL:

D. Actual Feeding

( ) - Present, served
( A ) - Absent, not served
( ) - Present, served twice

page 3
 SBFP Form 4

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________

ACTUAL FEEDING POST FEEDING

ATTENDANCE
NAME OF PUPIL Nutritional Status Days Feeding
Percentage
Ht Wt Date Present Days
101 102 ### 104 105 ### ### ### ### ### 111 112 113 114 115 116 117 118 119 120 cm kg Taken NS (A) (B) (A/B)*100
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
TOTAL: AVERAGE:

D. Actual Feeding

( ) - Present, served
( A ) - Absent, not served
( ) - Present, served twice

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