HSCMDA Masterlist and Record Form

School Based Deworming ( For School-Age Learners)

School: SINALOC ELEMENTARY SCHOOL

Division: EL SALVADOR CITY

Sex 4Ps
No. Surname First Name Age Date of Birth Complete Address Name of Drug Given Date Given Remarks
M F Yes No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Prepared by: Verified by: Date Submitted:

_____________________________________ _______________________________ _________________

Class Adviser School Head/Principal