Reporting Form 2a-Grade Level

School Based Weekly IronFollc Acid (WIFA) Supplementation

Round1 (/):_____ Round2 (/):_____ Reporting Month:________________
Grade level: 7(/):_____ 8(/):_____9(/):_____ 10(/):_____ ALS (/):_____
Region: __________ Division: ____________ District: __________________________________

School ID: 342199 Name of School: SHS within TCS Address: POBLACION 14, TINGLOY BATANGAS
Classrooms: 4

Total
No. of
Not
Given WIFA is
given
WIFA not
Enrollment WIFA REMARKS
Supple give
Supplem
ments (based
ents in
codes)
Name of
Section
Classroom Total No. of
Total No. of Total No. of
Female Numbe
Enrolled Female % Number % 1 2 3
Learners with r
Learners Learners consent
 Total
Submitted by: Validated by: Noted by:
__________________________________ ____________ __________________________ ________________________ _________
Grade Level Chairman Date School Nurse Principal
Reporting Form 2b-Grade Level
School Based Weekly IronFollc Acid (WIFA) Supplementation

Round1 (/):_____ Round2 (/):_____ Reporting Month:________________

Region: __________ Division: ____________ District: __________________________________ Date: ___________

School ID: _________ Name of School: ____________________ Address: ________________________________________________

Given WIFA Not given WIFA Total No. of WIFA is not give
Enrollment Supplements Supplements (based in codes)
Total No. of
Grade Sections/Classr
Level REMARKS
ooms
Total No. of Total No. of Total No. of
Enrolled Female Female Learners Number % Number % 1 2 3
Learners Learners with consent

GRADE XI 4 180 79 79 73 92% 6 8%

GRADE XII 3 160 65 65 54 83% 11 17%

Total 7 340 144 144 127 88% 17 12%

Submitted by: Validated by: Noted by:

CARISA B. MANALO 10/1/2019 BHONG ALVAREZ JUVIE ANN P. GABRIELES 10/1/2019

WIFA Supplemental Point Person Date School Nurse Principal Date
Reporting Form 3-District Level
School Based Weekly IronFollc Acid (WIFA) Supplementation
Round1 (/):_____ Round2 (/):_____ Reporting Month:________________
Grade level: 7(/):_____ 8(/):_____ 9(/):_____ 10(/):_____ ALS (/):_____ School Year:_________
Region: __________ Division: ____________ District: __________________________________ Date: ___________
School ID: _________ Name of School: ____________________ Address: ________________________________________________ Total No. Schools: _____

Given WIFA Not given WIFA Total No. of WIFA is not give
Enrollment Supplements Supplements (based in codes)

School Name of School Total No. of REMARKS

ID
Total No. of Total No. of Female
Enrolled Female Learners Number % Number % 1 2 3
Learners Learners with
consent

Total
Submitted by: Validated by: Approved by:

__________________________________ ____________ ___________________________________ _____________________________ ____________

District WIFA Point Person Date School Nurse Direct Supervisor Date
Reporting Form 4-Division Level
School Based Weekly IronFollc Acid (WIFA) Supplementation
Round1 (/):_____ Round2 (/):_____ Reporting Month:________________
Grade level: 7(/):_____ 8(/):_____ 9(/):_____ 10(/):_____ ALS (/):_____ School Year:_________

Region: __________ Division: ____________ Date: __________ Total No. Of Districts: __________________________________

Given WIFA Not given WIFA Total No. of WIFA is not give
Enrollment Supplements Supplements (based in codes)
Name of Total No. of REMARKS
District Schools
Total No. of Total No. of Total No. of
Enrolled Female Female Learners Number % Number % 1 2 3
Learners Learners with consent

Total
Submitted by: Validated by: Noted by:

__________________________________ ____________ ___________________________________ _____________________________ ____________

District WIFA Point Person Date Division Nurse-In-Charge School Division Superintendent Date
Date
Reporting Form 5-Regional Level
School Based Weekly IronFollc Acid (WIFA) Supplementation
Round1 (/):_____ Round2 (/):_____ Reporting Month:________________
Grade level: 7(/):_____ 8(/):_____ 9(/):_____ 10(/):_____ ALS (/):_____ School Year:_________
Region: __________ Division: ____________ Date: __________ Total No. Of Divisions: __________

Given WIFA Not given WIFA Total No. of WIFA is not give
Enrollment Supplements Supplements (based in codes)

Name of Total No. of Total No. of

Total No. of REMARKS
Division Districts Schools
Total No. of Total No. of Female
Enrolled Female Learners Number % Number % 1 2 3
Learners Learners with
consent

Total
Submitted by: Checked by: Noted by:

________________________________ ____________ _____________________________ ____________ _________________________ ____________

WIFA Focal Person Date Chief, ESSD Date Director Date
Reporting Form 1-List of Female Learners per Classroom Annex A
School Based Weekly IronFollc Acid (WIFA) Supplementation
Region: __________ Division: ___________________ District: __________________ Reporting Month: _______________________
School ID: _________ Name of School: ____________________________ Address: ________________________________________________
Grade Level: __________ Section/Classroom __________________________ Number of Female Learners: ____________ School Year: _________

1st Round 2nd Round

Consent
JULY AUGUST SEPTEMBER JANUARY FEBRUARY MARCH
Reason Why WIFA
No Name of Female Learner W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 notindicate) is given(Please Remarks
Y N (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat (Dat
e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e) e)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
*Consent Given

Submitted by: Noted by: Codes for reasons why WIFA is not given
1. Not Dewormed
__________________________________ ____________ __________________________________ _____________ 2. On therapeutic treatment for anemia
Class Adviser Date Grade Level Chairman Date 3. with persistent mild reaction like gastric discomfort