Ang aking anak na si _____________________, _________ Ang aking anak na si _____________________, _________

(Pangalan ng Bata) (Gr. at Sec.) (Pangalan ng Bata) (Gr. at Sec.)

( ) ay pinahihintulutan kong painumin ng gamot na ( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________ ngayong SY ____________ sa buwan ng ____________

Pangalan at Pirma ng magulang Pangalan at Pirma ng magulang

( ) ay hindi ko pinahihintulutang painumin ng gamot na ( ) ay hindi ko pinahihintulutang painumin ng gamot na
PAMPURGA dahil siya ay: PAMPURGA dahil siya ay:
( ) nagtatae o may LBM ( ) may lagnat ( ) nagtatae o may LBM ( ) may lagnat
( ) masakit ang tiyan ( ) may hika o asthma ( ) masakit ang tiyan ( ) may hika o asthma
( ) kagagaling pa lang sa sakit ( ) may sakit sa puso ( ) kagagaling pa lang sa sakit ( ) may sakit sa puso
( ) may allergy sa anumang gamot ( ) may allergy sa anumang gamot

Ang aking anak na si _____________________, _________
(Pangalan ng Bata) (Gr. at Sec.)
( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________
Ang aking anak na si _____________________, _________
(Pangalan ng Bata) (Gr. at Sec.)
( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________

Pangalan at Pirma ng magulang Pangalan at Pirma ng magulang

( ) ay hindi ko pinahihintulutang painumin ng gamot na ( ) ay hindi ko pinahihintulutang painumin ng gamot na
PAMPURGA dahil siya ay: PAMPURGA dahil siya ay:
( ) nagtatae o may LBM ( ) may lagnat ( ) nagtatae o may LBM ( ) may lagnat
( ) masakit ang tiyan ( ) may hika o asthma ( ) masakit ang tiyan ( ) may hika o asthma
( ) kagagaling pa lang sa sakit ( ) may sakit sa puso ( ) kagagaling pa lang sa sakit ( ) may sakit sa puso
( ) may allergy sa anumang gamot ( ) may allergy sa anumang gamot

Ang aking anak na si _____________________, _________
(Pangalan ng Bata) (Gr. at Sec.)
( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________
Ang aking anak na si _____________________, _________
(Pangalan ng Bata) (Gr. at Sec.)
( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________

Pangalan at Pirma ng magulang Pangalan at Pirma ng magulang

( ) ay hindi ko pinahihintulutang painumin ng gamot na ( ) ay hindi ko pinahihintulutang painumin ng gamot na
PAMPURGA dahil siya ay: PAMPURGA dahil siya ay:
( ) nagtatae o may LBM ( ) may lagnat ( ) nagtatae o may LBM ( ) may lagnat
( ) masakit ang tiyan ( ) may hika o asthma ( ) masakit ang tiyan ( ) may hika o asthma
( ) kagagaling pa lang sa sakit ( ) may sakit sa puso ( ) kagagaling pa lang sa sakit ( ) may sakit sa puso
( ) may allergy sa anumang gamot ( ) may allergy sa anumang gamot

Ang aking anak na si _____________________, _________
(Pangalan ng Bata) (Gr. at Sec.)
( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________
Ang aking anak na si _____________________, _________
(Pangalan ng Bata) (Gr. at Sec.)
( ) ay pinahihintulutan kong painumin ng gamot na
PAMPURGA ng mga DepEd/DOH Personnel
ngayong SY ____________ sa buwan ng ____________

Pangalan at Pirma ng magulang Pangalan at Pirma ng magulang

( ) ay hindi ko pinahihintulutang painumin ng gamot na ( ) ay hindi ko pinahihintulutang painumin ng gamot na
PAMPURGA dahil siya ay: PAMPURGA dahil siya ay:
( ) nagtatae o may LBM ( ) may lagnat ( ) nagtatae o may LBM ( ) may lagnat
( ) masakit ang tiyan ( ) may hika o asthma ( ) masakit ang tiyan ( ) may hika o asthma
( ) kagagaling pa lang sa sakit ( ) may sakit sa puso ( ) kagagaling pa lang sa sakit ( ) may sakit sa puso
( ) may allergy sa anumang gamot ( ) may allergy sa anumang gamot
DepEd Form 1
NATIONAL SCHOOL DEWORMING MONTH SY _____________
Masterlist and Recording Form for Soil Transmitted Helminthiasis

Division/District: _ALBAY/___________________________ Date: __________________

School: __________________________________________
School Address: ___________________________________
Grade Level/Section: _______________________________
Birth Sex Dewormed 4P's Member IPs Member
Name of Pupils/Students
Age Date M F Address Y N Y N Y N Remarks
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
35
36
37
38
39
40

LEGEND: Month of _______________

IPs - Indigenous People 5-9 y/o 10-19 y/o Grand
Total
 Grand
M F Total M F Total Total
Enrolment
Dewormed
Accomplished by: % of Accomplishment
4Ps Enrolled
4Ps Dewormed
Class Adviser 4Ps % of Accomplishment
(Signature Over Printed Name) IPs Enrolled
IPs Dewormed
IPs % of Accomplishment
DepEd Form 2 (Elem)

NATIONAL SCHOOL DEWORMING MONTH

SY _________ Month of ___________

Province: _ALBAY______________________________________
District: ______________________________________________
School: _____________________________________________
Address: _____________________________________________
Date: ______________________________________________

5-9 years old

*Enrolment **Dewormed % of Accomplishment 4Ps Enrolled 4Ps Dewormed

Grade
M F Total M F Total M F Total M F Total M F Total
Kinder
Grade I
Grade II
Grade III
Grade IV
Grade V
Grade VI
Grand Total
*Enrolment = All Enrolment (4Ps + non 4Ps + IPs + not IPs)
**Dewormed = All pupils/students dewormed (4Ps + non 4Ps + IPs + not IPs)

Accomplished by:

Principal/School Head
(Signature Over Printed Name)
DepEd Form 2 (Elem)

NATIONAL SCHOOL DEWORMING MONTH

SY _________ Month of ___________

Province: _ALBAY______________________________________
District: ______________________________________________
School: _____________________________________________
Address: _____________________________________________
Date: ______________________________________________

10-19 years old

*Enrolment **Dewormed % of Accomplishment 4Ps Enrolled 4Ps Dewormed

Grade
M F Total M F Total M F Total M F Total M F Total
Kinder
Grade I
Grade II
Grade III
Grade IV
Grade V
Grade VI
Grand Total
*Enrolment = All Enrolment (4Ps + non 4Ps + IPs + not IPs)
**Dewormed = All pupils/students dewormed (4Ps + non 4Ps + IPs + not IPs)

Accomplished by:

Principal/School Head
(Signature Over Printed Name)
MONTH
_____

4Ps % of IPs (Indigenous People) IPs % of

IPs Dewormed
Accomplishment Enrolled Accomplishment
M F Total M F Total M F Total M F Total
MONTH
_____

4Ps % of IPs (Indigenous People) IPs % of

IPs Dewormed
Accomplishment Enrolled Accomplishment
M F Total M F Total M F Total M F Total
DepEd Form 2 (Sec)

NATIONAL SCHOOL DEWORMING MONTH

SY _________ Month of ___________

Province: _ALBAY______________________________________
District: ______________________________________________
School: _____________________________________________
Address: _____________________________________________
Date: ______________________________________________

10-19 years old

*Enrolment **Dewormed % of Accomplishment 4Ps Enrolled 4Ps Dewormed

Grade
M F Total M F Total M F Total M F Total M F Total
Grade 7
Grade 8
Grade 9
Grade I0
Grade 11
Grade 12
Grand Total
*Enrolment = All Enrolment (4Ps + non 4Ps + IPs + not IPs)
**Dewormed = All pupils/students dewormed (4Ps + non 4Ps + IPs + not IPs)

Accomplished by:

Principal/School Head
(Signature Over Printed Name)
MONTH
_____

4Ps % of IPs (Indigenous People) IPs % of

IPs Dewormed
Accomplishment Enrolled Accomplishment
M F Total M F Total M F Total M F Total
 DepEd Form 3 (Elem)
NATIONAL SCHOOL DEWORMING MONTH
SY _________ Month of ___________

Province: _ALBAY______________________________________
District: ____________________________________________
Address: ____________________________________________
Date: ____________________________________________

5-9 years old

*Enrolment Dewormed % of Accomplishment 4Ps Enrolled 4Ps Dewormed

No. School
M F Total M F Total M F Total M F Total M F Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Grand Total
*Enrolment = All Enrolment (4Ps + non 4Ps + IPs + not IPs)
**Dewormed = All pupils/students dewormed (4Ps + non 4Ps + IPs + not IPs)

Accomplished by: Approved by:

Nutrition District Coordinator Distric

(Signature Over Printed Name) (Signature O
 10-19 years old

*Enrolment **Dewormed % of Accomplishment 4Ps Enrolled 4Ps Dewormed

No. School
M F Total M F Total M F Total M F Total M F Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Grand Total
*Enrolment = All Enrolment (4Ps + non 4Ps + IPs + not IPs)
**Dewormed = All pupils/students dewormed (4Ps + non 4Ps + IPs + not IPs)

Accomplished by: Approved by:

Nutrition District Coordinator Distric

(Signature Over Printed Name) (Signature O
MONTH
_____

IPs (Indigenous People)

4Ps % of Accomplishment IPs Dewormed IPs % of Accomplishment
Enrolled
M F Total M F Total M F Total M F Total

Approved by:

District Supervisor
(Signature Over Printed Name)
 IPs (Indigenous People)
4Ps % of Accomplishment IPs Dewormed IPs % of Accomplishment
Enrolled
M F Total M F Total M F Total M F Total

Approved by:

District Supervisor
(Signature Over Printed Name)
 DepEd Form 3 (Sec)
NATIONAL SCHOOL DEWORMING MONTH
SY _________ Month of ___________

Province: _ALBAY______________________________________
District: ____________________________________________
Address: ____________________________________________
Date: ____________________________________________

10-19 years old

*Enrolment **Dewormed % of Accomplishment 4Ps Enrolled 4Ps Dewormed

No. School
M F Total M F Total M F Total M F Total M F Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Grand Total
*Enrolment = All Enrolment (4Ps + non 4Ps + IPs + not IPs)
**Dewormed = All pupils/students dewormed (4Ps + non 4Ps + IPs + not IPs)

Accomplished by: Approved by:

Nutrition District Coordinator Distric

(Signature Over Printed Name) (Signature O
MONTH
_____

IPs (Indigenous People)

4Ps % of Accomplishment IPs Dewormed IPs % of Accomplishment
Enrolled
M F Total M F Total M F Total M F Total

Approved by:

District Supervisor
(Signature Over Printed Name)