NATIONAL DEWORMING MONTH

Region
Provinc
e
District
Division
School:

Grade
No. of Enrolled Children With consent Children Dewormed
Level

4 P's Non 4 P's TOTAL 4 P's Non 4 P's TOTAL 4 P's Non 4 P's TOTAL
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12

TOTAL 0 0 0 0 0 0 0 0 0

Accomplished by: Noted by:

School Point Person

(Name and School Principal (Name and
Signature) Signature)
Date Accomplished Date Accomplished
 Precautionary
Measure (seriously
Consented
ill, with abdominal Adverse %
to
No. of pain, diarrhea, who Event Dewormed
Deworming Refused Deworming
consent has previous and (Total
(as (as indicated in
form hypersensitivity Number Dewormed/
indicated in consent form)
returned with deworming No.
consent
drug ( annex B Enrolled
form)
MDAP Guide #1
page 14)

0 0 0 0 0

ncipal (Name and

)
omplished
NATIONAL DEWORMING MONTH
Region
Province
Division
District CLUSTER
School

Precautionary
Measure (seriously
ill, with abdominal %
Consented to Refused
No pain, diarrhea, who Adverse Dewormed
Deworming Deworming
Grade consent has previous Event (Total
No. of Enrolled Children With consent Children Dewormed (as indicated (as indicated
Level form hypersensitivity and Dewormed/
in consent in consent
returned with deworming Number No.
form) form)
drug ( annex B Enrolled
MDAP Guide #1
page 14)

4 P's Non 4 P's TOTAL 4 P's Non 4 P's TOTAL 4 P's Non 4 P's TOTAL
Kinder
Grade I
Grade II
Grade III
Grade IV
Grade V
Grade VI
SPED

TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Accomplished by: Noted by:

School Point Person
(Name and School Principal (Name and
Signature) Signature)
Date
Date Accomplished
Accomplished