Republic of the Philippines

Department of Education
REGION III
Schools Division Office of City of Malolos

QUALITY FORM FOR Document Code: SDO-MALOLOS-SGOD-SHN-QF-002

Revision: 01
QMS AND ISO 9001:2015 Effectivity date: 02-05-2021

Name of Office:
MONITORING FORM FOR HEALTH PROGRAMS SGOD-School Health and Nutrition
Section

Name of School: ____CMIS-ATLAG________________

Start of Inspection: _________AM/PM

SCHOOL-BASED IMMUNIZATION

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Number of learners G.Level M F G.Level M F G.Level M F G.Level M F
who were given G1 G1 G1 G1
measles containing G7 G7 G7 G7
vaccine
Number of learners G1 G1 G1 G1
who were given G7 G7 G7 G7
tetanus diphtheria
Number of learners G4 G4 G4 G4
who were given
human papilloma
virus
Other Vaccines:
1.

2.

3.

VISION SCREENING

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Number of learners who G.Level M F G.Level M F G.Level M F G.Level M F
passed the vision K K K K
screening G1 G1 G1 G1
G2 G2 G2 G2
G3 G3 G3 G3
G4 G4 G4 G4
G7 G7 G7 G7
G10 G10 G10 G10
Number of learners who K K K K
failed the vision screening G1 G1 G1 G1
G2 G2 G2 G2
G3 G3 G3 G3
G4 G4 G4 G4
G7 G7 G7 G7
G10 G10 G10 G10

SCHOOL CLINIC

Address:  Government Center, Brgy. Bulihan, City of Malolos, Bulacan

Contact Numbers: (044) 812-2006 and (044) 812-2007
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 Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Presence of designated
clinic

Number of weighing
scales (specify the type) 2

Tools used for taking

height TAPE MEASURE

Number of first aid kits

2

Number of medical
thermometers 1

Number of blood pressure

apparatus 1

Number of school
personnel who has
training on basic life 18
support and/or first aid

MENTAL HEALTH
Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Presence of licensed mental
health professionals or other
certified mental health 0
professionals

Capacity building activities

conducted 0

Number of learners who

sought guidance counseling or
0
life coaching

Number of cases of violence

against children committed in
0
schools

Number of cases of bullying or

peer abuse 0

Number of cases of suicide

and attempted suicide among
0
learners and school personnel

TOBACCO CONTROL (including Electronic Nicotine and Non-Nicotine Delivery System)

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 Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Presence of IEC materials (please
specify)

Presence of Child Protection

Committee (frequency of meeting,
agenda, date of last meeting with
tobacco agenda, record of
monitoring on stores within 100-
meter perimeter, frequency of
monitoring, date of last monitoring)

Number of partnerships

Number of partnerships that have

proper partnership instrument
needed

Number of partnerships that include

a provision in the MOA/DOD that
the partner/donor is not connected
to the tobacco industry, does not
received funding from tobacco
companies, or does not sell
cigarettes

NATIONAL PREVENTIVE DRUG EDUCATION

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Components of preventive drug
education program

National Drug Education Program

coordinator 1

Number of classrooms with NDEP

corners 18

Number of Participants/ Members/

Coaches/ Advisers per activity 18

FEEDING PROGRAM

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Number of Beneficiaries
Funding source of feeding program
SBFP

Budget allocation

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Funds Utilized

Resources used for feeding

program

Funding source of agricultural and

fishery resources

GPP Contribution to SBFP Veg Qty Cost Veg Qty Cost Veg Qty Cost Veg Qty Cost

% contribution of GPP to SBFP

expenses

Amount of financial assistance

given to SBFP

Number of food handlers dewormed

Designated SBFP room with

handwashing area and complete
inventory of utensils

SCHOOL CANTEEN AND FOOD HANDLING

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Canteen Management

Validity date of sanitary permit

Number of canteen personnel and

food handlers

Number of canteen personnel and

food handlers with health certificate

Compliance with Food Category

(Green, Yellow and Red) for cooked
foods

Presence of Inspection Table and

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Summary List for manufactured foods
and beverages

Presence of signage with “Only

Healthy Foods and Drinks are Served
in the Premises”

Advocacy (e.g. regulation and

prohibition of marketing of unhealthy
foods and beverages in the school
and within at least 100 meter radius
outside the school)

Conduct of Food Safety Inspection

(specify if any)

SOLID WASTE MANAGEMENT

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Implementation of Ecological Solid
Waste Management (Please Specify)

Stakeholders who actively engaged

OPERATION AND MAINTENANCE OF SANITATION FACILITIES

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Frequency of cleaning

Average cost of monthly

bills/maintenance

Funding source

ADOLESCENT AND REPRODUCTIVE HEALTH

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Components of ARH

ARH coordinator

Number of Participants/ Members/

Coaches/ Advisers per activity

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HEALTH STANDARDS

Item 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Orientation on the Respiratory
Etiquette and Other Protective
Measures
Access to Protective Health Supplies

Routine Cleaning/Disinfection

Health Screening and Referral

System

Activities and Event Management

System (Compliance with IATF
Protocols)

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Checked by: Checked by: Checked by: Checked by:

Signature over printed name Signature over printed name Signature over printed name Signature over printed name
Designation: Designation: Designation: Designation:
Date/Time Ended: Date/Time Ended: Date/Time Ended: Date/Time Ended:

Page 6 of 6