DepEd Form 1A.

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

School ID: 108001 Name of School: TAMBO ELEMENTARY SCHOOL Type: 1 1- Public 2-Private School Year: 2023-2024 Grade Level/Section: I -RAMBUTAN

Adress of the School: TAMBO MALAKI, INDANG, CAVITE District: INDANG Division: CAVITE Region: IV-A CALABARZON
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)

1 Arcenal, Prince Nathan, Cielo M 2 08-25-2023

2 Baes, Darenz Jairiell, Marges 3/12/2016 6M 2 PAYAG
3 Bocalan, Tyron Cane, Villamor 02/14/2017 6M 08-15-2023
4 Colinares, Joshua, Salazar 06/14/2017 6M 2 PAYAG
5 Cruz, Dwayne Alzane, Nuestro 09/23/2015 7M 2 PAYAG
6 Dimas, Neil, Atoli 09/28/2016 6M 08-15-2023
7 Durin, Bricx Kyron, Matel 09/13/2017 6M PAYAG
8 Felipe, Romjuvien, Lumio 2/2/2016 7M 08-24-2023
9 Logroño, Ashley Jade, De Guzman 10/13/2017 5M 2 08-28-2023 X
10 Malolos, Baby Anghel Jr., Jadormio 1/12/2015 7M 08-15-2023
11 Olaybal, Jeremy, Vicente 08/30/2014 9M 08-21-2023
12 Oyales, Jefferson, Mandocdoc 02/26/2016 7M PAYAG
13 Quinito, Mark, Payusan 10/7/2015 8M 08-15-2023
14 Quiñones, Zavion Kristoff, Cruz 06/21/2017 6M
15 Rogando, Ferdinand Miguel, Albis 11/2/2017 6M 2 08-28-2023 X
16 Salayon, Sam Reynier, Montesa 7/5/2017 6M 08-17-2023
17 Sierra, Yuan Tyler, Campillanes M 08-15-2023
18 Tolentino, Jolo, Agsangre 10/13/2015 7M 2 PAYAG
19 Vejerano, Reynel, Valizado 9/2/2016 7M
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 / - received 2
M-Male 2-NHTS- doses/year
F-Female Non-4Ps X - received only 1
dose or no
dose/year
(6) (14)
(1) (2) (3) (4) (5) (7)
 Part 3. Status of
Deworming by
No. Name of SAC Address Birthday Age Sex SE Status 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)

20 Atole, Michaella Jane, Francisco F 2 08-25-2023 X

21 Besenio, Niorelyn, Clutario 11/26/2014 8F PAYAG
22 Camarillo, Keziah, Revilla 05/22/2017 6F
23 Canicula, Kate Natalie, Cosino 12/24/2016 6F 2 08-15-2023 X
24 Dalit, Daniella Rose, Peñano 07/16/2017 6F 08-15-2023
25 Erni, Theresia Tiffany 2/12/2016 6F 2 08-22-2023 X
26 Ersando, Amethyst Nigella, Aguinaldo 09/26/2016 6F 2 PAYAG
27 Hernandez, Alia, Espiritu 08/15/2017 6F 2 08-15-2023 X
28 Manglicmot, Yzzabella, Arcabado 09/15/2016 7F 08-15-2023
29 Matibag, Elijah, Balutan 10/15/2016 6F 2 PAYAG
30 Munda, Trixie Eunice, Creus 06/20/2017 6F 2 PAYAG
31 Oyales, Jaylen, S. F
32 Oyales, Megan Jane, Degala 11/2/2017 6F 2 PAYAG
33 Pellos, Eliana Bella, Nipay 06/21/2017 6F 2 08-22-2023 X
34 Rodil, Jhen Xzavrina, Creus 8/12/2016 6F 2 PAYAG
35 Valenzuela, Keizhia Gabrielle, Tenebro 07/28/2017 6F 08-21-2023
Total No. Enrolled: 35 M: 19 NHTS-4Ps No. NHTS-4Ps No. w/ ADR: No.NHTS- 4Ps No. w/ ADR: No. recvd 2 doses:
F: 16 Dewormed: Dewormed:
NHTS-non4Ps No. recvd 1 or 0
No. NHTS non No. NHTS non dose:
4Ps 4Ps
Dewormed: Dewormed:

Total: Total:

Accomplished by Classroom Adviser: ERICKA JANE M. SEVERINO

Noted by Grade Level Chairman:
Date:
tion: I -RAMBUTAN
 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: