Deworming Forms

Republic of Philippines
Department of Education
Region 02 – Cagayan Valley
Schools Division of the City of Ilagan
Isabela National High School Compound, San Vicente, City of Ilagan, Isabela, 3300
Telephone: (078) 624-0077
Email: Ilagan.depedro2@gmail.com
Annex B.1
Form 1 – Classroom Level
NATIONAL SCHOOL DEWORMING DAY
Region: ______________ Division: ________________________ District: ________________________________
School ID: ______________________ Name of School: ___________________________________________________
Enrolment: _____________________ Grade level & Section:

_______________________________________________
Enrolment Dewormed Remarks
NAME OF CHILD Actions Taken

Hand- Feeding Tooth-
Non- Non- washing brushing
4P’s 4P’s
4P’s 4P’s
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Accomplished by: Noted by:
REBECCA D.MATIAS
____________________________________ REBECCA D.MATIAS
Class Adviser Clinic Teacher/ Health & Nutrition Coordinator
Date Accomplished: ____________________
Telephone: (078) 624-0077
Form 2 – School Level Annex B.2
NATIONAL SCHOOL DEWORMING DAY
Region: 02 Division: City of Ilagan District: Ilagan South
School ID: 103384
Name of School: AGGASSIAN ELEMENTARY SCHOOL
NO. OF
CHILDREN
ENROLMENT
DEWORMED
GRADE LEVEL REMARKS
Non-
4P’s 4P’s
4P’s Non-
4P’s
KINDER 0 56 0 46 46 out of 56 dewormed
GRADE I 3 55 3 54 57 out of 58 dewormed
GRADE II 2 53 2 53 100% dewormed
GRADE III 2 56 2 37 39 out of 58 dewormed
GRADE IV 15 50 15 46 61 out of 65 dewormed

GRADE V 12 65 12 61 73 out of 77 dewormed
GRADE VI 13 43 13 33 46 out of 56 dewormed
TOTAL 47 378 47 330 OUT OF 425 pupils,377 were dewormed
Accomplished by: Noted by:
REBECCA D.MATIAS MARIBEL B.CONTILLO,EdD.

Clinic Teacher/ Health & Nutrition Coordinator Principal II
Date Accomplished: MARCH 13,2019
Telephone: (078) 624-0077
PORMA NA PAHINTULOT
Pinapahintulutan ko ang aking anak na si _______________________, (pangalan ng paaralan) __________________________
baitang ___________, para mabigyan ng mga sumusunod na gamot.

__________________________________________________________________________________________________________
Hindi ko pinapahintulutan ang aking anak na si _______________________, (pangalan ng paaralan) __________________________ baitang
___________, para mabigyan ng mga sumusunod na gamot.
Ang rason: ________________________________________________________________
Pampurga (Albendazole 400mg)

Pampurga (Mebendazole 500mg)
Vitamin A (Retinol Palmitate 200,000 IU Soft Gel Capsule)
Multivitamins + Iron (Multilem Plus Syrup120ml)
Lubos kong naunawaan ang nakasaad sa pahintulot na ito.
Lagda ng Magulang / Tagapag-alaga: _______________________________________
Pangalan ng Magulang/ Tagapag-alaga: _____________________________________
Petsa: ___________________
Telephone: (078) 624-0077
PORMA NA PAHINTULOT
Pinapahintulutan ko ang aking anak na si _______________________, (pangalan ng paaralan) __________________________
baitang ___________, para mabigyan ng mga sumusunod na gamot.
___________________________________________________________________________________________________________
Hindi ko pinapahintulutan ang aking anak na si _______________________, (pangalan ng paaralan) __________________________ baitang
___________, para mabigyan ng mga sumusunod na gamot.
Ang rason: ________________________________________________________________
Pampurga (Albendazole 400mg)

Pampurga (Mebendazole 500mg)
Lubos kong naunawaan ang nakasaad sa pahintulot na ito.
Lagda ng Magulang / Tagapag-alaga: _______________________________________
Pangalan ng Magulang/ Tagapag-alaga: _____________________________________
Petsa: ___________________
Telephone: (078) 624-0077
CONSENT FORM
I allow my child ____________________________ of class _____ sec ____ to be

administered the following medicines:
I will not allow my child ____________________________ of class _____ sec ____ to be
Deworming Tablet (Albendazole 400mg)

Deworming Tablet (Mebendazole 500mg)
Signature of Parent / Guardian ___________________
Name of Parent / Guardian ___________________
Date ___________________
__________________________________________________________________________________________________
CONSENT FORM
I allow my child ____________________________ of class _____ sec ____ to be

I will not allow my child ____________________________ of class _____ sec ____ to be

Deworming Tablet (Albendazole 400mg)

Deworming Tablet (Mebendazole 500mg)
Signature of Parent / Guardian ___________________
Name of Parent / Guardian ___________________
Date ___________________

Deworming Forms

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Republic of Philippines

Form 1 – Classroom Level

NATIONAL SCHOOL DEWORMING DAY

Region: ______________ Division: ________________________ District: ________________________________

School ID: ______________________ Name of School: ___________________________________________________

Enrolment: _____________________ Grade level & Section:

Enrolment Dewormed Remarks

NAME OF CHILD Actions Taken

Accomplished by: Noted by:

Class Adviser Clinic Teacher/ Health & Nutrition Coordinator

Date Accomplished: ____________________

Form 2 – School Level Annex B.2

NATIONAL SCHOOL DEWORMING DAY

Region: 02 Division: City of Ilagan District: Ilagan South

School ID: 103384

Name of School: AGGASSIAN ELEMENTARY SCHOOL

KINDER 0 56 0 46 46 out of 56 dewormed

GRADE I 3 55 3 54 57 out of 58 dewormed

GRADE II 2 53 2 53 100% dewormed

GRADE III 2 56 2 37 39 out of 58 dewormed

GRADE IV 15 50 15 46 61 out of 65 dewormed

GRADE VI 13 43 13 33 46 out of 56 dewormed

TOTAL 47 378 47 330 OUT OF 425 pupils,377 were dewormed

Accomplished by: Noted by:

REBECCA D.MATIAS MARIBEL B.CONTILLO,EdD.

Date Accomplished: MARCH 13,2019

Pinapahintulutan ko ang aking anak na si _______________________, (pangalan ng paaralan) __________________________

baitang ___________, para mabigyan ng mga sumusunod na gamot.

Pampurga (Albendazole 400mg)

Lubos kong naunawaan ang nakasaad sa pahintulot na ito.

Lagda ng Magulang / Tagapag-alaga: _______________________________________

Pangalan ng Magulang/ Tagapag-alaga: _____________________________________

Pinapahintulutan ko ang aking anak na si _______________________, (pangalan ng paaralan) __________________________

baitang ___________, para mabigyan ng mga sumusunod na gamot.

Pampurga (Albendazole 400mg)

Lubos kong naunawaan ang nakasaad sa pahintulot na ito.

Lagda ng Magulang / Tagapag-alaga: _______________________________________

Pangalan ng Magulang/ Tagapag-alaga: _____________________________________

I allow my child ____________________________ of class _____ sec ____ to be

Deworming Tablet (Albendazole 400mg)

Signature of Parent / Guardian ___________________

Name of Parent / Guardian ___________________

I allow my child ____________________________ of class _____ sec ____ to be

I will not allow my child ____________________________ of class _____ sec ____ to be

Deworming Tablet (Albendazole 400mg)

Signature of Parent / Guardian ___________________

Name of Parent / Guardian ___________________

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Region: Division: District: __________________

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Pinapahintulutan ko ang aking anak na si _, (pangalan ng paaralan) ____

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I allow my child __________________________ of class _ sec __ to be

I allow my child __________________________ of class _ sec __ to be

I will not allow my child __________________________ of class _ sec __ to be