Annex B.

Form 1 – Classroom Level

NATIONAL SCHOOL DEWORMING DAY

Region: ______________ Division: ________________________ District: ________________________________

School ID: ______________________ Name of School: ___________________________________________________
Enrolment: _____________________ Grade level & Section: _______________________________________________

Enrolment Dewormed Remarks

NAME OF CHILD Actions Taken
Hand- Feeding Tooth-
Non- Non- washing brushing
4P’s 4P’s 4P’s 4P’s
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.

Accomplished by: Noted by:

_____________________________________ _______________________________________
Class Adviser Clinic Teacher
Date Accomplished: ____________________
Form 2 – School Level Annex B.2

NATIONAL SCHOOL DEWORMING DAY

Region: ______________ Division: ________________________ District: ______________________________

School ID: ________________________________________________________
Name of School: ___________________________________________________

NO. OF CHILDREN
ENROLMENT DEWORMED
GRADE LEVEL Non- REMARKS
4P’s Non- 4P’s 4P’s
4P’s
KINDER
GRADE I
GRADE II
GRADE III
GRADE IV
GRADE V
GRADE VI
TOTAL

Accomplished by: Noted by:

_________________________________ ___________________________________
School Principal District Supervisor

Date Accomplished: ____________________________