Form 1 - Classroom Level

School-based Weekly

Region: _IX__ Division : Zamboanga Sibugay

School ID: _500241____ Name of School: Talairan Integrated School
Grade Level/Section: _10-CHRYSOPRASE__ No. of Students Enrolled: _________

Consent* 1st Round

LRN NAME OF LEARNER July August
W1 W2 W3 W4 W1 W2
Y N
(date) (date) (date) (date) (date) (date)

125562080003 AMPALO, CHERYMAE X

124335080013 BOCOBO, BABY JANE X

125562080007 CALAMIAN, JESSA X

125561130058 CALIB OG, NORHANA X

125550080016 CASIPONG, ANGELYN X

125562080013 DELOS SANTOS, MYRA JANE X

127959080111 EGARGO, MARICHU X

125550080023 GARNESO, CHARLENE X

125561080010 GRAVINO, JANETH X

125550080028 LABASTILLA, LOVELY SWEET X

125550080042 PAHAYAHAY, JERAHMAE X

125562080022 PLAIDA, MICHELLE X

125561130009 ROMERO, JOUNNA X

125561130064 RUIZ, WENDY JANE X

125550080045 SABADO, KRISTINE X

SABAT, JOIRAH MAE X

125562080025 SIATON, CARHINE GRACE X

125562080026 SINAMPAGA, JEZYL NIÑA X

125561120050 SUMANDURAN, PRINCESS X

125562080029 TAYROS, CHARLENE X

*Consent given Administered by:

DANILYN B. BARBER
Class Adviser Date
l-based Weekly Iron Folic Acid (WIFA) Supplementation

Date: School Year: 2018-2019

No. of Female Learners: 20 Address: ______ Talairan Integrated School

Provided With Iron Folic Acid Supplements

1st Round 2nd Round
August September January February March
W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2
(date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date)

Noted by:

ANTONIA M. LATAO
Date Head Teacher Date
 Annex A1

March REMARKS
W3 W4
(date) (date)
Form 2a–Classrooml Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 / 9 10 ALS

Region: IX Division : Zamboanga Sibugay Date: March 26, 2018

School ID: 500241 Name of School: Talairan Integrated School Address:

Enrollment Given WIFA Supplements Not Given WIFA Supp.

Section Total No. of Total No. of
Enrolled Female Number % Number
Learners Learners
Topaz 50 22 22 100% 0

Administered by: Noted by:

KENNETH J. CALAD ANTONIA M. L

Class Adviser Head Teacher

Date: 3/26/2018 Date:

 Annex A2

cid (WIFA) Supplementation

Round 2

9 10 ALS

Date: March 26, 2018 School Year: 2017-2018

Talairan, Buug, ZSP

Not Given WIFA Supp. Remarks

(Reasons why WIFA

% is not given)

ANTONIA M. LATAO
Head Teacher

3/26/2018
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: