HO Form 1.

Deworming Coverage of PSAC Reached Through the Community by Barangay

Barangay: SAN JUAN Municipality: SAN SIMON Province/City: PAMPANGA Region: III
Part 1. Master list of PSAC Part 2. Deworming Status During Each Round
Part 3. Status of
IN-SCHOOL SE Status July Round January Round Deworming in a
Year
Out of
Sex
School (ü)-w/ (ü)-w/
1-NHTS 4Ps ADR, ADR, (ü)-received 2
No. specify specify doses/year
(HSN) Name of Client Address Birthday (ü)- (ü)-
type type
Grade/ dewormed, dewormed,
Name of School Remarks Remarks
Level 2-NHTS Non write date write date
M- Male Place dewormed dewormed (x)-received onlyn 1
4Ps
check (x)-no ADR (x)-no ADR dose orno
(ü) dose/year
F- Female 3-Non NHTS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
 27
28
29
30
31
32
33
34
Total M- NHTS 4Ps -
F- NHTS Non4Ps
Non NHTS