Form 1 - Classroom Level Annex A1

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: _______________________ Division : Date: School Year: __________

School ID: ____________________ Name of School:
Grade Level/Section: _____________ No. of Students Enrolled: _________ No. of Female Learners: ________ Address: ____________________________________________

Provided With Iron Folic Acid Supplements

Consent* 1st Round 2nd Round
LRN NAME OF LEARNER July August September January February March REMARKS
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Y N
(date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date)

*Consent given Administered by: Noted by:

Class Adviser Date Grade Level Teacher Date

Form 2a–Classrooml Level Annex A2

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

Region: _______________________ Division : ______________________________ Date: _______________ School Year: _______________

School ID: _________ Name of School: _________________________________ Address: _______________________________________________

Enrollment Given WIFA Supplements Not Given WIFA Supp. Remarks

Section Total No. of Total No. of (Reasons why WIFA

Enrolled Female Number % Number % is not given)
Learners Learners

Administered by: Noted by:

Class Adviser Grade Level Teacher

Date: _______________ Date: _______________
Form 2b – School Level Annex A2a

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

Region: _______________________ Division : ______________________________ Date: _______________ School Year: _____________

School ID: _________ Name of School: _________________________________ Address: _____________________________________________

Enrollment Given WIFA Supplements Not Given WIFA Supp. Remarks

Section Total No. of Total No. of (Reasons why WIFA

Enrolled Female Number % Number % is not given)
Learners Learners

7
8
9
10
ALS

TOTAL

Submitted by: Noted by:

School Principal District Supervisor

Date: _______________ Date: _______________

Validated By:
School Nurse
Form 3– District Level Annex A3

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

School Year: __________________

Region: _______________________ Division : _________________________________ District: ______________________

Enrollment Given WIFA Supp. Not Given WIFA Supp. Remarks

School ID School Total No. of Total No. of (Reasons why

Enrolled Female Number % Number % WIFA is not
Learners Learners given)

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Submitted by: Approved by:

District Supervisor
Date: ________ Validated By: Date: _______________
School Nurse
Form 4 - Division level Annex A5

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2
Grade Level 7 8 9 10 ALS

Region: ____________
Division: ________________
Enrolment
Given WIFA
Given WIFA Supp. Not Given WIFA
District Total No. of Total No. of Remarks
Enrolled Female Number % Number % (Reasons why WIFA is not given)
Learners Learners

Submitted by: Approved by:

_______________________________________
Schools Division Supervisor/ Superintendent
Date Accomplished: ______________________

Validated by:
Division Nurse In-Charge
Form 5– Regional Level Annex A6

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2
Grade Level 7 8 9 10 ALS

Region: __________________

Enrolment Given WIFA Supplementation Not Given WIFA

Remarks
Division (Reasons why WIFA
Total No. of Total No. of
Number % Number % is not given)
Enrolled Learners Female Learners

Prepared by: Approved by: Noted by:

______________________________
WIFA Focal Person Director (BLSSD) HSD
Date Accomplished: Date Accomplished: Date Accomplished: