Republic of the Philippines

Department of Education
REGION I
SCHOOLS DIVISION OFFICE OF URDANETA CITY
______________________________________________________________________
SCHOOL DENTAL HEALTH CARE PROGRAM SY-2021-2022

MONITORING TOOL FOR TOOTHBRUSHING ACTIVITY AT HOME

For the Month of _________________

NAME OF LEARNER: ______________________________________________________________

NAME OF PARENT/GUARDIAN: _____________________________________________________
GRADE: __________ SCHOOL: ______________________________________________________

DAY AFTER AFTER AFTER PARENT/ GUARDIAN ADVISER

BREAKFAS LUNCH DINNE SIGNATURE SIGNATURE - DATE
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ADVISER PRINTED NAME AND SIGNATURE SCHOOL HEAD PRINTED NAME AND SIGNATURE

Address: High School Drive San Vicente Urdaneta City, Pangasinan

Telephone No: Telefax: 075 568 3054
 Republic of the Philippines
Department of Education
REGION I
SCHOOLS DIVISION OFFICE OF URDANETA CITY
______________________________________________________________________
/SGOD-SHS-MJMC

Address: High School Drive San Vicente Urdaneta City, Pangasinan

Telephone No: Telefax: 075 568 3054
 Republic of the Philippines
Department of Education
REGION I
SCHOOLS DIVISION OFFICE OF URDANETA CITY
______________________________________________________________________

Address: High School Drive San Vicente Urdaneta City, Pangasinan

Telephone No: Telefax: 075 568 3054