Recording Form 1 - List of Female Learners per Classroom ANNEX A

School Based Weekly Iron Folic Acid (WIFA) Supplementation

Region IV - A Division: Cavite District: GMA Reporting Month:____________________
School 301192 Name of School : GMATHS Address:_ GMA Cavite Date:____________________
Grade Level: G12 Section/Classroom:_Karakol Number of Female Learners: 32 School Year: 2019-2020

Consent 1st Round 2nd Round

July August September January February March Reason why WIFA is
NO. Name of Female Learner not given (Please Remarks
Y N W4 W1 W2 W3 W4
W1 (July W2 (July W3 (July
(August (August (August (August (August W1 6)(Sept. W213)
(Sept. W3 (Sept. W4 (Sept. W1 W2 (Jan. W3 (Jan. W4 (Jan. W1 (Feb. W2 (Feb. W3 (Feb. W4 (Feb. W1 W2 (Mar. W3 (Mar. W4 (Mar. Indicate CODES)
1-5) 8-12) 22-26) 20) 27) (Jan. 10) 17) 24) 31) 7) 14) 21) 28) (Mar.6) 13) 20) 27)
2) 9) 16) 23) 30)
1 De Guzman, Mela Rose D. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

2 Gayoma, Maybel F. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

3 Glabo, Marielle Johanna C. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

4 Labrador, Lyln G. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

5 Lerios, Claire Justine D. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

6 Macasa, Evalyn √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

7 Makiramdam, Elenita M. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

8 Mangilimotan, Ryjane S. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

9 Mantilla, Jenny B. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

10 Mariano, Erikha A. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

11 Masagnay, Andrea D. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

12 Medina, Angel D. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

13 Motas, Angelica T. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

14 Murillo, Genalyn A. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

15 Nacion, Dianna B. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

16 Navarra, Eunice √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

17 Nuestro, Jennalyn S. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

18 Padawan, Jesiery √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

19 Pangilinan, Elyza A. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

20 Patulot, Kim Ashley D. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

21 Porcillo, Zennia R. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

22 Robosa, Faye Christine B. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

23 Reyes, Daisy Rose B. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

24 Saba, April Alyssa A. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

25 Sael, Danica √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

26 Salimo, Shiela Mae M. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

27 Satiada, Erika S. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

28 Sescar, Izzelle Faye F. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

29 Soriano, Krizelle C. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

30 Tapungot, Lea May L. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

31 Timon, Robilyn √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

32 Villanueva, Maureen P. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

TOTAL 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 32 31 31 31 31 31 31

*Consent Given **Codes for reasons why WIFA is not given:

Submitted By; Noted By: 1. Not Dewormed
Irene V. Higoy 2. On Therapeutic Treatment for Anemia
Class Adviser Date Grade Level Chairman Date 3. With Persistent Mild Reaction like Gastric Discomfort
Recording Form 2a - Grade Level

School Based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1(/):__________ Round 2(/):__________

Grade Level: 7(/):__________ 8(/):__________ 9(/):__________ 10(/):__________ ALS(/):__________ Reporting Month:____________________

Region:____________________ Division:____________________ District:____________________ School Year:____________________
School ID:____________________ Name of School:____________________ Address:____________________ Date:____________________
Total No. of Section/Classroom:____________________

Enrollment Given WIFA Supplements Not Given WIFA Supplements Total No. of WIFA is not give (based in codes)

Name of Section/Classroom Remarks

Total No. of Enrolled Total No. of Female Total No. of Female
Number % Number % 1 2 3
Learners Learners Learners with Consent

TOTAL

Submitted By; Validated By: Noted By:

__________________
Grade Level Chairman Date School Nurse Date Principal Date
 Republic of the Philippines
Region ____________________

NOTIFICATION LETTER

DIVISION:____________________
SCHOOL;____________________
ADDRESS:____________________
DATE:____________________
STUDENT'S NAME:____________________
STUDENT'S ADDRESS:____________________
NAME OF PARENT/GUARDIAN:____________________

Dear Parent/Guardian:
This school as a Public Elementary School will conduct the following health services to the children
in coordination with the Department of Health (DOH) and the Local Government Unit (LGU).

National School Deworming

Weekly Iron Folic Acid Supplementation for Adolescent Females

This notification is being issued to you as information of the activity that will be conducted on SY 2017-
2018. Should you have further questions/clarification on this matter, please get in touch with the Principal/School
head.
Thank you.

Very Truly Yours,

Name of Principal/School Heads

This is to acknowledge receipt of the Notification Letter regarding the conduct of free school based
health services.
I have read and understood the information regarding the intended health services to be given to my child'
(Please check in the box provided)

Yes, I allow my child to be provided the health services

Yes, I allow my child but only for these services:

I will NOT allow my child to receive the health service benefits.

Reason:

Signature of Guardian
Recording Form 2b - School Level

School Based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1(/):__________ Round 2(/):__________ Reporting Month:____________________

Region:____________________ Division:____________________ District:____________________ School Year:____________________

School ID:____________________ Name of School:____________________ Address:____________________ Date:____________________

Enrollment Given WIFA Supplements Not Given WIFA Supplements Total No. of WIFA is not give (based in codes)
Total No. of
Grade Level Remarks
Section/Classroom Total No. of Enrolled Total No. of Female Total No. of Female
Number % Number % 1 2 3
Learners Learners Learners with Consent

TOTAL

Submitted By; Validated By: Noted By:

__________________
WIFA Supplemental Point Person Date School Nurse Date Principal Date
Recording Form 3 - District Level

School Based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1(/):__________ Round 2(/):__________

Grade Level: 7(/):__________ 8(/):__________ 9(/):__________ 10(/):__________ ALS(/):__________ Reporting Month:____________________

Region:____________________ Division:____________________ District:____________________ School Year:____________________
School ID:____________________ Name of School:____________________ Address:____________________ Date:____________________
Total No. of School:____________________

Enrollment Given WIFA Supplements Not Given WIFA Supplements Total No. of WIFA is not give (based in codes)

School ID Name of School Remarks

Total No. of Enrolled Total No. of Female Total No. of Female
Number % Number % 1 2 3
Learners Learners Learners with Consent

TOTAL

Submitted By; Validated By: Approved By:

___________________________________ __________________
District WIFA Point Person Date School Nurse Date District Supervisor Date
Recording Form 4 - Division Level

School Based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1(/):__________ Round 2(/):__________ Reporting Month:____________________

Grade Level: 7(/):__________ 8(/):__________ 9(/):__________ 10(/):__________ ALS(/):__________ School Year:____________________

Region:____________________ Division:____________________ Date:____________________ Total No. of District:____________________

Enrollment Given WIFA Supplements Not Given WIFA Supplements Total No. of WIFA is not give (based in codes)

Name of District Total No. of School Remarks

Total No. of Enrolled Total No. of Female Total No. of Female
Number % Number % 1 2 3
Learners Learners Learners with Consent

TOTAL

Submitted By; Validated By: Approved By:

___________________________________ __________________
Division WIFA Point Person Date Division Nurse In Charge Date School Division Superintendent Date