Form 1 - Classroom Level Annex A1

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: VII Division : Toledo City Date: School Year: 2020-2021

School ID: 303318 Name of School: Luray II Barangay High School
Grade Level/Section: 7-JOY No. of Students Enrolled: 50 No. of Female Learners: 23 Address: Luray II, Toledo City, Cebu

Provided With Iron Folic Acid Supplements

Consent* 1st Round 2nd Round
LRN NAME OF LEARNER ADDRESS July August September January February March REMARKS
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Y N
(date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date)
BABOR MARGIE Capt Claudio, Toledo
City
BAGAHANSOL KEIRFEN VAL Capt Claudio, Toledo
City
BRIONES MARYMAR Poblacion, Toledo City

CABANTE DHARLINE JANE Poblacion, Toledo City

CABATAS APRIL JOY Poblacion, Toledo City

CABRILES MARY LOVELY GRACE Poblacion, Toledo City

CANILLO ANTHONETTE Poblacion, Toledo City

CANOOG NICE Poblacion, Toledo City

CANOY GEE - ANN Poblacion, Toledo City

CAPARIDA JENESA Poblacion, Toledo City

CAPARIDA SHEILO Poblacion, Toledo City

CARAGON JOVELYN Poblacion, Toledo City

CLIMACO MARY TYRENE DINACELLE Poblacion, Toledo City

COLANGGO DIVINE Poblacion, Toledo City

CORDOVA FRANCIS RICKA Poblacion, Toledo City

DEADA JASMINE Poblacion, Toledo City

DEL SOCORRO WENDELYN Poblacion, Toledo City

DELA CRUZ DESHERA Poblacion, Toledo City

DELICA MHEGEA Poblacion, Toledo City

DIZON CJ Poblacion, Toledo City

ENOY AZNIRA Poblacion, Toledo City

EDOLOVERIO CANAE Poblacion, Toledo City

GELLICA JONNA Poblacion, Toledo City

*Consent given Administered by: Noted by:

KRIZZIE JOY DALAPO CAILING

Class Adviser Date Grade Level Teacher Date

Form 2a–Classrooml Level Annex A2

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

Region: ________________ Division : Date: _______________ School Year: _______________

School ID: ______________ Name of School: _________________________________ Address: ___________________________________

Enrollment Given WIFA Supplements Not Given WIFA Supp. Remarks

Section Total No. of
Total No. of Female
Enrolled Number % Number % (Reasons why WIFA is not given)
Learners Learners

Administered by: Noted by:

Class Adviser Grade Level Teacher

Date: _______________ Date: _______________

Form 2a
Form 2b – School Level Annex A2a

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

Region: _______________________ Division : _______________________________Date: _______________ School Year: _____________

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

Enrollment Given WIFA Supplements Not Given WIFA Supp. Remarks

Section Total No. of Total No. of
(Reasons why WIFA is not
Enrolled Female Number % Number %
Learners Learners given)

7
8
9
10
ALS

TOTAL

Submitted by: Noted by:

School Principal District Supervisor

Date: _______________ Date: _______________

Validated By:
Form School Level School Nurse
Form 3– District Level Annex A3

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2

Grade Level 7 8 9 10 ALS

School Year: __________________

Region: _______________________ Division : _________________________________ District: ______________________

Enrollment Given WIFA Supp. Not Given WIFA Supp. Remarks

School ID School Total No. of Total No. of

(Reasons why WIFA is not
Enrolled Female Number % Number %
Learners Learners given)

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

District Supervisor
Date: ________ Validated By: Date: _______________

School Nurse
Form 4 - Division level Annex A5

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2
Grade Level 7 8 9 10 ALS

Region: ____________
Division: __________________________
Enrolment
Given WIFA
Given WIFA Supp. Not Given WIFA
District Total No. of Total No. of Remarks
Enrolled Female Number % Number % (Reasons why WIFA is not given)
Learners Learners

Submitted by: Approved by:

_______________________________________
Schools Division Supervisor/ Superintendent
Date Accomplished: ______________________

Validated by:

Division Nurse In-Charge

Form 5– Regional Level Annex A6

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2
Grade Level 7 8 9 10 ALS

Region: __________________

Enrolment Given WIFA Supplementation Not Given WIFA

Remarks
Division (Reasons why WIFA
Total No. of Total No. of
Number % Number % is not given)
Enrolled Learners Female Learners

Prepared by: Approved by: Noted by:

______________________________
WIFA Focal Person Director (BLSSD) HSD
Date Accomplished: Date Accomplished: Date Accomplished:
Form 1 - Classroom Level Annex A1
School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: _______________________ Division : 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
LRN NAME OF LEARNER July August September January February March REMARKS
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Y N

*Consent given Administered by: Noted by:

Class Adviser Date Grade Level Teacher Date