DepEd Form 1A.

List of SAC Enrolled Per Class and Deworming Status by MDA Round

School ID: Name of School: Type: 1- Public 2-Private School Year: Grade Level/Section:

Adress of the School: District: Division: Region:

Part 1. List of SAC Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status of
Deworming by
No. Name of SAC Address Birthday Age Sex SE Status First Round of MDA Sept-Nov.'2023) Second Round of MDA (March-May' 2024) School Year
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed / - with ADR, / - dewormed, / - withADR Remarks / - received 2
write date specify Remarks write date specify type doses/year
F-Female Non4Ps X - received only 1
dewormed type dewormed
X - no ADR X - no ADR dose or no
X - not X - not dose/year
(6) (14)
(1) (2) (3) (4) (5) (7) dewormed dewormed (13)
(8) (9) (10) (11)
(12)
 Part 1. List of SAC Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status of
Deworming by
No. Name of SAC Address Birthday Age Sex SE Status First Round of MDA (August'2022) Second Round of MDA (Feb.'2023) School Year
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed, / - with ADR, / - dewormed, / - with ADR Remarks / - received 2
write date specify Remarks write date specify type doses/year
F-Female Non-4Ps X - received only 1
dewormed type dewormed
X - no ADR X - no ADR dose or no
X - not X - not dose/year
(6) (14)
(1) (2) (3) (4) (5) (7) dewormed (10) dewormed (13)
(8) (9) (11)
(12)

Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No.NHTS- 4Ps No. w/ ADR: No. recvd 2 doses:
F: Dewormed: Dewormed:
NHTS-non4Ps No. recvd 1 or 0
No. NHTS non No. NHTS non dose:
4Ps 4Ps
Dewormed: Dewormed:

Total: Total:
 4Ps 4Ps
Dewormed: Dewormed:

Total: Total:

Accomplished by Classroom Adviser:

Noted by Grade Level Chairman:
Date:
 DepEd Form 1B. List of Adolescents Enrolled Per Class and Deworming Status by MDA Round

School ID: Name of School: Type: 1- Public 2-Private School Year: Grade Level/Section:

Adress of the School: District: Division: Region:

Part 1. List of Adolescents Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status of
Deworming by
No. Name of Adolescent Address Birthday Age Sex SE Status First Round of MDA (August'2022) Second Round of MDA (Feb.'2023) School Year
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed, / - with ADR, Remarks / -dewormed, / - withADR Remarks / - received 2
write date specify write date specify type doses/year
F-Female Non4Ps X - received only
dewormed type dewormed X - no ADR
X - not X - no ADR 1dose or no
dewormed X - not dose/year
(6) (7)
(1) (2) (3) (4) (5) (10) dewormed (12) (13)
(8) (9) (11) (14)
 Part 1. List of Adolescents Enrolled Part 2. Deworming Status During Each Round of MDA Part 3. Status
ofDeworming
No. Name of Adolescent Address Birthday Age SexSE Status First Round of MDA (August'2022) Second Round of MDA (February'2023) by SchoolYear
1-NHTS-4Ps
M-Male 2-NHTS- / - dewormed, / - with ADR, Remarks / - dewormed, / - with ADR, Remarks / - received 2
write date specify write date specify type doses/year
F-Female Non-4Ps X - received only
dewormed type dewormed X - no ADR
X - not X - no ADR 1 dose or no
dewormed X - not dose/year
(6) (7) (14)
(1) (2) (3) (4) (5) (10) dewormed (12)
(8) (9) (11) (13)

Total No. Enrolled: M: NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No. NHTS-4Ps No. w/ ADR: No. recvd 2
F: Dewormed: Dewormed: doses:
NHTS-
non4Ps No. NHTS non No. NHTS non No. recvd 1 or 0
4Ps Dewormed: 4Ps Dewormed: dose:

Total: Total:

Accomplished by Classroom Adviser:

Noted by Grade Level Chairman:
Date:
Accomplished by Classroom Adviser:
Noted by Grade Level Chairman:
Date:
 School
DepEd Form 2. Consolidation of MDA Coverage of SAC (Kinder to Grade 12) Year: 2022-2023
School Name of
ID: School: Type: 1-Public 2-Private
Address of the
School: District: Division: Cavite Province Region: IV- A

First MDA Round (August' 2022) Second MDA Round (February' 2023) No. Given 2 doses By SY

Grade Total No. Total Number Dewormed No. w/ Total Number Dewormed No. w/ NHTS
adverse adverse NHTS- Remarks
Level Enrolled Remarks Non-
drug drug 4Ps Total (9)
(1) (2) (5) 4Ps
NHTS NHTS reactions NHTS NHTS reactions (8a)
(4) Total (7) (8b)
4Ps Non4Ps Total 4Ps Non4Ps
(3a) (3b) (6a) (6b)
Kinder
Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8
Grade 9

Grade
10
Grade
11
Grade
12
SPED
ALS
Total 0 0 0 0 0 0 0 0 0 0 0 0 0
Percent (%):
Column Total
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Divide Row Total
Multiplied by 100
Accomplished by School Clinic Teacher:
Noted by School Principal:
Date Accomplished: