Form 1

NATIONAL SCHOOLS DEWORMING DAY

Deworming Checklist

Province: SORSOGON Name of School: Bulan North CS - B

Division: SORSOGON School Address: Zone 5, Bulan, Sor
District: Bulan North Total Enrollment: 41
Grade Level and Section: V- Diamond
Member
SEX
Name of Child of 4P’s Given Action
AGE Remarks
(Surname – Given - MI) Albendazole Taken
M F Yes No
1 Adorna, Mark Lester
2 Elpos, Gabriel
3 Floro, Dyemeon Riseol
4 Fungo, Johann Philip
5 Gelilio, Kym Jechris L.
6 Gerona, Jared
7 Gilbas, Lorenn Chryston Deian D.
8 Gloriane, Marc Ivan H.
9 Godalle, John Michael
10 Gotladera, Clark Hanz Denver D.
11 Granado, John Clein N
12 Hiloma, Shemuel A.
13 Joven, John Mike N.
14 Mape, Victor
15 Mercado, Zeus Zhan’ra
16 Sancho, Vinz Efren L.
17 Agne, Daniela Q.
18 Arrogante, Allysa Jean T.
19 Chua Denise Luanne G.
20 Dumdum, Rayne Gabrielle M.
21 Dungca, Fiona Reign G.
22 Dy, Leila Victoria L.
23 Ercilla, Jashie
24 Espena, Seiyuri Dylan G.
25 Gliane, Cassandra C.
26 Gloriane, Zhanley Jice G.
27 Goboli, Janine G.
28 Gojar, Rella Alexandrei R.
29 Guran, Tiffany Claire G.
30 Jamorol, Jaysiel Claire G.
31 Morata, Nathalie Rose P.
32 Novela, Heart P.
33 Pena, Tiffanie G.
34 Raymundo, Samantha Zyrill
35 Sambajon, Althea Jane V.
36 Solomon, Veronica V.
37 Tagub, Rhiana A.
38 Tan, Nichola Danielle G.
39 Tan, Sophia Nicole L.
40 Tumbukon, Maria Denicka G.
41 Villegas, Alexa Jade H.
Remarks:

(R) Refused (M) with mild adverse effect Prepared by: Noted:
(CD) Contraindicated (MM) with moderate AE
(E) Enrolled (S) with severe AE Rowella M. Macandog Christy R. Magcayan
(EO) Enrolled in another (SS) with serious AE Adviser School Head
Barangay
(O) Others (explain)
Date Submitted: _____________