Recording Form 1 - List of Female Learners

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: _____________________ Division: District: _____________ Reporting Month: __________ 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
No. NAME OF LEARNER July August September January February March Reasons why
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 WIFA is not
given (Please
Y N indicate
(date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date)
codes**)

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
TOTAL
*Consent given Administered by: Noted by:
** Codes for reasons why WIFA is not given:
1. not dewormed
Class Adviser Date Grade Level Teacher Date 2. on therapeutic treatment on anemia
3. with persistent mild reaction like gastric discom
Annex A1

REMARKS
 FA is not given:
d
nt on anemia
e gastric discomfort
Reporting Form 2a–Classrooml Level Annex A2

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 Reporting Month:__________________

Grade Level 7 8 9 10 ALS

Region: _______________________ Division : ____________________ District : _____________ Date: _______________ School Year: __________

School ID: _________ Name of School: _________________________________ Address: ____________________ Total no. of Sections: __________________

Total No. of WIFA not

Enrollment Given WIFA Supplements Not Given WIFA Supp. given based on codes
Name of
Section/Classroom
Total No. of
Total No. of Total No. of Female
Enrolled Female Number % Number % 1 2 3
Learners with
Learners Learners Consent

Total
Administered by: Noted by:
 Class Adviser Grade Level Teacher

Date: _______________ Date: _______________

___

___________________

REMARKS
Reporting Form 2b – School Level Annex A2a

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 Reporting Month:_____________________

Grade Level 7 8 9 10 ALS

Region: _______________________ Division : _________________________________ Date: _______________ School Year: ___________

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

Total No. of WIFA not

Enrollment Given WIFA Supplements Not Given WIFA Supp. given based on codes
Total
Section No. of REMARKS
Section Total No. of Total No. of Total No. of
Female
Enrolled Female Number % Number % 1 2 3
Learners with
Learners Learners Consent

7
8
9
10

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 Reporting Month:__________________

Grade Level 7 8 9 10 ALS

School Year: __________________ Date:________________

Region: _______________________ Division : _________________________________ District: ______________________

Total No. of WIFA not given

Enrollment Given WIFA Supp. Not Given WIFA Supp. based on codes

Total No. of Total No. of Total

School ID Name of School No. of REMARKS
Female
Enrolled Female Number % Number % 1 2 3
Learners with
Learners Learners Consent

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

District Supervisor
Date: ________ Validated By: Date: _______________
School Nurse
Form 4 - Division Level
School-based Weekly Iron Folic Acid (WIFA) Supplementation
Round 1 Round 2 Reporting Month:__________________
Grade Level 7 8 9 10 ALS

Region: ____________ Date:__________________

Division: ________________ Total No. of Districts: _____________

Enrolment Total No. of WIFA not

Given WIFA Given WIFA Supp. Not Given WIFA given based on codes

District REMARKS
Total No. of Total No. of Total No. of
Female
Enrolled Female with Number % Number % 1 2 3
Learners Learners Learners
Consent

Total
Submitted by: Approved by:
 _______________________________________
Date Accomplished: ______________________ Schools Division Supervisor/ Superintendent
Validated by:

Division Nurse In-Charge

Form 5– Regional Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 Reporting Month:__________________
Grade Level 7 8 9 10 ALS

Region: __________________ Date:__________________

Given WIFA Total No. of WIFA not

Enrolment Not Given WIFA
Supplementation given based on codes

Division Total No. of Total No. of

Total No. of
Enrolled Female Learners Number % Number % 1 2 3
Female Learners with Consent
Learners
 Total
Prepared by: Approved by: Noted by:

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