Annex

A1

Form 1 – Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: I Division : Urdaneta City Date: November 10, 2017 School Year: 2017-2018

School ID: 300405 Name of School: Lananpin National High School Address: Pinmaludpod, Urdaneta City

Grade Level/Section: _______________________ Number of Students Enrolled _____________________ Number of Female Learners
___________________

Round 1 Round 2

LRN Consent Provided With Iron Folic Acid Supplements REMARKS

With Without Month of ___________ Month of ___________ Month of ____________
Name of Consent Consent W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Learner Indicate Indicate Indicate Indicate Indicate Indicate Indicate Indicate Indicate Indicate Indicate Indicate

date date date date date date date date date date date date

ABAD,
CRISSA
1. MAE O

ALVARO,
2. DISSY V.
 BALLEST
EROS,
ROCHELL
3. ES

BITUIN,
GABRIEL
4. LE B.

CLEMENT
E,
KEZZIAH
JAMMAE
5. B

CORPUZ,
CHANEL
BERNICE
6. M

FABRO,
MEKYLA
7. JULIA D.

FERNAND
EZ,
MYKAELL
8. A E.

JANER,
KAYLA
9. MAE A

LAGUNA,
MELODY
10. B

LANDAYA
N,
ZHANTAL
11. CLARE S

LIBUNAO,
JENNILYN
12. D

LUCENA,
ALIAH
13.. MARIE T

14. MARANIO
N, JYZEE
 M

MAYAND
OC,
15. ALEAH T.

NITURA,
BERNADE
16. TTE C

OBSINA,
17. MARIEL

PARINAS,
AUDREY
18. JANE A

SAN
VICENTE,
ROSE
19. ANN R

SHARIEF,
20. HAZEL B

TALPE,
21. ROSELYN

TUAZON,
LOIDA
22. NICOLE M

VALDEZ,
23. MELONY

VILLACER
A,
JENNILYN
24. B

SALDUA,
25. AIRENE

TOTAL
Administered by: Noted by:
__________________________________ _______________________________________
_ _
Class Adviser Grade Level Chair
Date: _________________________ Date: ___________________________________