Form 1 to DepEd Memorandum No. 39, s.

2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – School

School: _________________________________

District: _________________________________

Division: ________________________________

Number of
Grade Level Number of Enrolment Learners
Section received HCK

Kindergarten

Grade I

Grade II

Grade III

Grade IV

Grade V

Grade VI

TOTAL

Submitted by:

________________________
School Administrator
Form 2 A to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – School

School: _________________________________

District: _________________________________

Division: ________________________________

Picture during the distribution of

Health Care Kit in SCHOOL.

Submitted by:

________________________
School Administrator
Form 2 B to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – School

School: _________________________________

District: _________________________________

Division: ________________________________

Picture of learner using the

Health Care Kit commodities

in TOOTHBRUSHING at home.

Picture of learner using the

Health Care Kit commodities

in HANDWASHING at home.

Submitted by:

________________________
School Administrator
Form 3 to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – District

District: _________________________________

Division: ________________________________

Number of Number of
Total Learners
Grade Level School Enrolment received HCK

Kindergarten

Grade I

Grade II

Grade III

Grade IV

Grade V

Grade VI

TOTAL

Prepared by:

___________________________
District SDHCP Coordinator

Noted:

________________________
PS District Supervisor
Form 4 A to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – District

District: _________________________________

Division: ________________________________

Pictures during the distribution of Health Care Kit in school.

Picture during the

Picture during the Picture during the
distribution of
distribution of distribution of
Health Care Kit
Health Care Kit Health Care Kit
in SCHOOL.
in SCHOOL. School #3
in SCHOOL.
School #1

Picture during the Picture during the Picture during the

distribution of distribution of distribution of
Health Care Kit Health Care Kit Health Care Kit
in SCHOOL.
in SCHOOL. School #6
in SCHOOL.

Picture during the Picture during the

Picture during the
distribution of distribution of
distribution of
Health Care Kit Health Care Kit
Health Care Kit
in SCHOOL.
in SCHOOL. in SCHOOL. School #9
School #7

Prepared by:

___________________________
District SDHCP Coordinator
Noted:
________________________
PS District Supervisor
Form 4 B to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – District

District: _________________________________

Division: ________________________________

Pictures of learners using the Health Care Kit commodities in TOOTHBRUSHING at HOME.

Picture of learner using the Picture of learner using the Picture of learner using the
Health Care Kit
Health Care Kit Health Care Kit commodities
commodities commodities in TOOTHBRUSHING
at HOME.
in TOOTHBRUSHING in TOOTHBRUSHING
School # 3

Picture of learner using the Picture of learner using the

Picture of learner using the
Health Care Kit
commodities
Health Care Kit Health Care Kit
in TOOTHBRUSHING
commodities commodities
at HOME.

in TOOTHBRUSHING in TOOTHBRUSHING School # 6

Picture of learner using the Picture of learner using the Picture of learner using the
Health Care Kit
Health Care Kit commodities
Health Care Kit
commodities in TOOTHBRUSHING
commodities
at HOME.

in TOOTHBRUSHING in TOOTHBRUSHING
School # 9

Prepared by:

___________________________
District SDHCP Coordinator
Noted:

________________________
PS District Supervisor
Form 4 C to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – District

District: _________________________________

Division: ________________________________

Pictures of learners using the Health Care Kit commodities in HANDWASHING at HOME.

Picture of learner using the Picture of learner using the Picture of learner using the
Health Care Kit
Health Care Kit Health Care Kit commodities
commodities commodities in HANDWASHING
at HOME.
in HANDWASHING in HANDWASHING
School # 3

Picture of learner using the Picture of learner using the

Picture of learner using the
Health Care Kit
commodities
Health Care Kit Health Care Kit
in HANDWASHING
commodities commodities
at HOME.

in HANDWASHING
in HANDWASHING School # 6

Picture of learner using the Picture of learner using the Picture of learner using the
Health Care Kit
Health Care Kit commodities
Health Care Kit
commodities in HANDWASHING
commodities
at HOME.

in HANDWASHING in HANDWASHING
School # 9

Prepared by:

___________________________
District SDHCP Coordinator
Noted:

________________________
PS District Supervisor
Form 5 to DepEd Memorandum No. 39, s. 2021

SCHOOL DENTAL HEALTH CARE PROGRAM – HEALTH CARE KIT

DISTRIBUTION REPORT – Division

Division: ________________________________

Number of
Number of Total Learners
Grade Level
District Enrolment received HCK

Kindergarten

Grade I

Grade II

Grade III

Grade IV

Grade V

Grade VI

TOTAL

Prepared by:

___________________________
Divisional SDHCP Coordinator

Recommending Approval:

________________________
SGOD Chief

Approved:

___________________________________
Schools Division Superintendent