Harmonized Schedule of Mass Drug Adm

for Selected Neglected Tropical Dise

Legend:
SCH=Schistosomiasis ALB=Albendazole
IS=In School
PZQ=Praziquantel
PP=Private Physician
LF=Lymphatic Filariasis
AH=At Home
DEC=Diethylcarbamazine citrate
O=Others

How to fill this form:

Example
4P's Beneficiary Deworming (ALB)
Under 5 y/o

Name Remarks
Yes No 1st Dose Date
IS PP AH
X X 1/10/2014 X
1. Juan Dela Cruz 10AM

GRADE:___11__
SECTION:____HUMSS____

4P's Beneficiary Deworming

Under 5 y/o

Name Remarks
Yes No 1st Dose Date
IS PP AH

1. Jonathan Faith F. Carvajal

2. John Renz G. Dalaten

3. Daniel De Guzman

4. Edmund M. Peralta

5. Mark Jayson U. Sabater

Glace Y. Abejuela

7. Hannah Mae F. Antineo

8. Christine Joy Bobiles

9. Angelica Jane Calinmlim

 4P's Beneficiary Deworming

Under 5 y/o
Name Remarks
Yes No 1st Dose Date
IS PP AH

10. Jessy Mikaela T. Cui

11. Angelyn Esteves

12. Princess Diane Flores

13. Jhonella Marie Gamoso

14. Katherine M. Garin

15. Monica Aila Getche

16. Rose Camille Lozano

17. Lyza Mae Mejia

18. Judith Ogana

19. Sharmine Joy Palisoc

20. Tricia Marie C. Prado

21. Mary Guen radam

22. Jessica Mae Salazar

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.
 4P's Beneficiary Deworming

Under 5 y/o
Name Remarks
Yes No 1st Dose Date
IS PP AH

37.

38.

39.

40.

TOTAL

Prepared by: Noted by:

_________________________________________ _________________________________________
 Form 1_2014
Classroom Record

ug Administration
pical Diseases

IMPORTANT REMINDER:
*Deworming=Albendazole
*Treatment of Schistosomiasis=Praziquantel
*Treatment of Filariasis=DEC + Albendazole
DO NOT give double dose of ALB for integrated treatment of helminthiasis and filariasis

SCH Deworming (ALB) LF

ks Remarks DEC+A Remarks
PZQ 2nd Dose Date LB
O IS PP AH O
X 7/10/2014 X X
11:30AM

SCH Deworming LF
ks Remarks DEC+A Remarks
PZQ 2nd Dose Date
O IS PP AH O LB
 SCH Deworming LF
ks Remarks DEC+A Remarks
PZQ 2nd Dose Date
O IS PP AH O LB
 SCH Deworming LF
ks Remarks DEC+A Remarks
PZQ 2nd Dose Date
O IS PP AH O LB

Approved by:
Form 1_2014
Classroom Record
________________________________________
Legend:
E=Enrolment SCH=Schistosomiasis
DA=Deworming Accomplishment PZQ=Praziquantel
MDA=Mass Drug Administration
% = #SE / Number Treated x 100%
TB= Total no. of Beneficiaries
How to fill this form:
Example

SY:__________________ Within Endemic Are

SCHOOL:________________________________

DA (IHCP)
MDA (SCH)
Grade E % %
ALB PZQ
1st dose
male
K
female
male
1
female
male
2
female
male
3
female
male
4
female
male
5
female
male
6
female
male
TOTAL
female

DA (IHCP)
MDA (SCH)
Grade E % %
ALB PZQ
1st dose
male
7
female
male
8
female
male
9
 9
female
male
10
female
male
11
female
male
12
female
male
TOTAL
female

Prepared by: Noted by:

_________________________________________ __________________
 Harmonized Schedule of Mass Drug Administration
for Selected Neglected Tropical Diseases

LF=Lymphatic Filariasis
DEC=Diethylcarbamazine citrate

n Endemic Area for: SCH ___YES ___NO

LF ___YES ___NO

DA (IHCP) TOTAL NO. OF B

MDA (LF)
% % Remarks
ALB ALB ALB
DEC+ALB TB %
2nd dose 1st 2nd

TOTAL

DA (IHCP) TOTAL NO. OF B

MDA (LF)
% % Remarks
ALB ALB ALB
DEC+ALB TB %
2nd dose 1st 2nd
 TOTAL

Approved by:

___________________________________ __________________________________
School Principal
 Form 2_2014
School Record

TOTAL NO. OF BENEFICIARIES

Remarks
% PZQ % DEC %

TOTAL NO. OF BENEFICIARIES

Remarks
% PZQ % DEC %
 Form 2_2014
___________________________________ School Record
 Harmonized Schedule of Mass Drug Administration
for Selected Neglected Tropical Diseases
Legend:
E=Enrolment SCH=Schistosomiasis LF=Lymphatic Filariasis
DA=Deworming Accomplishment PZQ=Praziquantel DEC=Diethylcarbamazine citrate
% = #SE / Number Treated x 100%
TB+ Total no. of beneficiaries
2019-2020 Number of Schools Within Endemic Area for: SCH
DepEd School Division of Dagupan City LF

K-6 7 - 12
School ALB ALB ALB ALB
E % % PZQ % DEC % E % % PZQ % DEC % TB
1st 2nd 1st 2nd
male
1. Juan L. Siapno ES
female
male
2. Lucao Elementary School
female
male
3. Malued ES & Special Science ES
female
male
4. West Central Elementary School I
female
male
5. West Central Elementary School II
female
male
6. Bacayao Sur Elementary School
female
male
7. Caranglaan Elementary School
female
male
8. Pascuala G. Villamil Elementary School
female
male
9. East Central Integrated School
female
10. Lasip Grande Elementary School male
female
male
11. Mangin Tebeng Elementary School
female
male
12. Pogo-Lasip Elementary School
female
male
13. Tambac Elementary School
female
male
14. Tebeng Elementary School
female
male
15. BLISS Elementary School
female
male
16. Bolosan Elementary School
female
male
17. Federico N. Ceralde Integrated School
female
male
18. Bonuan Boquig Elementary School
female
male
19. Leon-Francisco Maramba ES
female
male
20. Victoria Q. Zarate Elementary School
female
male
21. Gen. Gregorio del Pilar Elementary Sch.
female
male
22. Mamalingling Elementary School
female
male
23. North Central Elementary School
female
male
24. Sabangan Elementary School
female
male
25. Salisay Elementary School
female
male
26. T. Ayson-Rosario Elementary School
female
male
27. Calmay Elementary School
27. Calmay Elementary School
female
male
28. Carael Elementary School
female
male
29. Lomboy Elementary School
female
male
30. Pantal Elementary School
female
male
31. Pugaro Integrated School
female
male
32. Salapingao Elementary School
female
male
33. Suit Elementary School
female
male
34. Juan P. Guadiz Elementary School
female
male
DCNHS
female
male
JJDVMVTHS
female
male
BBNHS
female
male
Carael NHS
female
male
Salapingao NHS
female
male
TOTAL
female

Prepared by: Noted by: Approved by:

Noreen B. Vidal _________________________________________ _________________________________________

Nurse II
 Form 3_2014
Division Record

4P's Beneficiary
ALB ALB Remarks
% % PZQ % DEC %
1st 2nd
 Form 3_2014
Division Record
 Harmonized S
for Sele
Legend:
E=Enrolment SCH=Schistosomiasis LF=Lymphatic Filariasis
DA=Deworming Accomplishment PZQ=Praziquantel DEC=Diethylcarbamazine citrate
% = #SE / Number Treated x 100%
TB+ Total no. of beneficiaries

SY:__________________ Number of Divisions Within Endemic Area for:

REGION:________________________________

K-6
DIVISION ALB ALB
E % % PZQ % DEC %
1st 2nd

TOTAL

Prepared by: Noted by:

_________________________________________ _________________________________________
monized Schedule of Mass Drug Administration
for Selected Neglected Tropical Diseases

SCH
LF

7 - 12 4P's Beneficiary
ALB ALB ALB ALB
E % % PZQ % DEC % TB % % PZQ %
1st 2nd 1st 2nd

Approved by:
______ _________________________________________
 Form 4_2014
Regional Record

Remarks
DEC %

Form 4_2014
Regional Record
 Form 5_2014
Central Office Record

Harmonized Schedule of Mass Drug Administration

for Selected Neglected Tropical Diseases
SY__________________
Legend:
ALB=Albendazole
PZQ=Praziquantel
DEC=Dietyhlcarbamazine citrate
% = Total Number of Enrollees / Total Number Treated x 100%

Total Number Treated ALB 1st ALB 2nd

PZQ
DEC

K-6 7 - 12 4P's Beneficiary

REGION PROVINCE Remarks

Enrolment ALB 1st % ALB 2nd % PZQ % DEC % Enrolment ALB 1st % ALB 2nd % PZQ % DEC % Enrolment ALB 1st % ALB 2nd % PZQ % DEC %

Region I-Ilocos Region Ilocos Norte

Region I-Ilocos Region Ilocos Sur
Region I-Ilocos Region La Union
Region I-Ilocos Region Pangasinan
Region II-Cagayan Valley Batanes
Region II-Cagayan Valley Cagayan
Region II-Cagayan Valley Isabela
Region II-Cagayan Valley Nueva Vizcaya
Region II-Cagayan Valley Quirino
Region III-Central Luzon Aurora
Region III-Central Luzon Bataan
Region III-Central Luzon Bulacan
Region III-Central Luzon Nueva Ecija
Region III-Central Luzon Pampanga
Region III-Central Luzon Tarlac
Region III-Central Luzon Zambales
Region IV A-Calabarzon Batangas
Region IV A-Calabarzon Cavite
Region IV A-Calabarzon Laguna
Region IV A-Calabarzon Quezon
Region IV A-Calabarzon Rizal
Region IV B-Mimaropa Marinduque
Region IV B-Mimaropa Occidental Mindoro
Region IV B-Mimaropa Oriental Mindoro
Region IV B-Mimaropa Romblon
Region IV B-Mimaropa Palawan
Region V-Bicol Albay
Region V-Bicol Camarines Norte
Region V-Bicol Camarines Sur
Region V-Bicol Catanduanes
Region V-Bicol Masbate
Region V-Bicol Sorsogon
Region VI-Western Visayas Aklan
Region VI-Western Visayas Antique
Region VI-Western Visayas Capiz
Region VI-Western Visayas Guimaras
Region VI-Western Visayas Iloilo
Region VI-Western Visayas Negros Occidental
Region VII-Central Visayas Bohol
Region VII-Central Visayas Cebu
Region VII-Central Visayas Negros Oriental
Region VII-Central Visayas Siquijor
Region VIII-Eastern Visayas Biliran
Region VIII-Eastern Visayas Eastern Samar
Region VIII-Eastern Visayas North Leyte
Region VIII-Eastern Visayas Northern Samar
Region VIII-Eastern Visayas Western Samar
Region VIII-Eastern Visayas South Leyte
Region IX-Zamboanga Peninsula Zamboanga del Norte
Region IX-Zamboanga Peninsula Zamboanga del Sur
Region IX-Zamboanga Peninsula Zamboanga Sibugay
Region X-Northern Mindanao Bukidnon
Region X-Northern Mindanao Camiguin
Region X-Northern Mindanao Lanao del Norte
Region X-Northern Mindanao Misamis Occidental
Region X-Northern Mindanao Misamis Oriental
Region XI-Davao Region Compostella Valley
Region XI-Davao Region Davao del Norte
Region XI-Davao Region Davao del Sur
Region XI-Davao Region Davao Oriental
Region XII-Soccksargen North Cotabato
Region XII-Soccksargen Sarangani
Region XII-Soccksargen South Cotabato
Region XII-Soccksargen Sultan Kudarat
CARAGA Agusan del Norte
CARAGA Agusan del Sur
CARAGA Dinagat Islands
CARAGA Surigao del Norte
CARAGA Surigao del Sur
ARMM Basilan
ARMM Lanao del Sur
ARMM Maguindanao
ARMM Sulu
ARMM Tawi-Tawi
CAR Abra
CAR Apayao
CAR Benguet
CAR Ifugao
CAR Kalinga
CAR Mountain Province
NCR Metropolitan Manila
TOTAL

Prepared by: Noted by: Approved by:

Form 5_2014
_________________________________________ _________________________________________ _________________________________________ Central Office Record