Form 1 - Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: I Division: SDO 1 Pangasinan Date : ________________________

School ID : ___________________ Name of School: _______________________________________
Grade Level : ___________________ Number of Students Enrolled: ________________________

Round 1 Round 2

Consent Provided With Iron Folic Acid Supplements

LRN Name of Learner Month of ___________________________ Month of _________________________ Month of _________________________

With Without
Consent Consent W1 W2 W3 W4 W1 W2 W3 W4 W1 W2
Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date
Administered by: Noted by:
___________________________________________________ _____________________________________________________
Class Adviser Grade Level Chair
Date: ____________________________________________ Date: _____________________________________________
 Annex A1

School Year : 2019-2020

Address: __________________________________________
Number of Female Learners: __________________

ents
________________________
W3 W4 Remarks
Indicate Date Indicate Date
______________

______________
Form 2 - School Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: 1 Division: SDO 1 Pangasinan Date : ________________________ School Year : 2019-2020

School ID : _________________________ Name of School: ____________________________________ Address: _____________________________________________
Grade Level : ______________________ Number of Students Enrolled: __________________________ Number of Female Learners: ______________________
Round 1 Round 2

Enrollment Given WIFA Supplements Not Given WIFA

Grade Level
Total No. of Enrolled Total No. of Enrolled Number % Number %
Students Female Students
Grade 7 #DIV/0! #DIV/0!
Grade 8 #DIV/0! #DIV/0!
Grade 9 #DIV/0! #DIV/0!
Grade 10 #DIV/0! #DIV/0!
Grade 11 #DIV/0! #DIV/0!
Grade 12 #DIV/0! #DIV/0!
ALS #DIV/0! #DIV/0!
TOTAL #DIV/0! #DIV/0!

Submitted by: Noted by:

______________________________________ _________________________________________
WIFA Coordinator School Head
Date Accomplished: _____________________

Validated by: _____________________

(Signature Over Printed Name)
 Annex A2

Year : 2019-2020
s: ____________________________________________________
r of Female Learners: ____________________________

Remarks
(Reasons why WIFA is not given)

________________________________
School Head