SBFP Form 1

Department of Education
Region ___

Master List Beneficiaries for School-Based Feeding Program (SBFP)

Division/Province: ______________________________________

Name of Principal : ____________________________________

City/ Municipality/Barangay : ____________________________

Name of Feeding Focal Person : _________________________

Name of School / School District : _________________________

No.

Name

Sex

Date of Birth
(MM/DD/YYYY)

Date of Weighing / Age in

Weight Height
Measuring
Years /
(Kg)
(cm)
(MM/DD/YYYY) Months

BMI for
6 y.o. Nutritional
and Status (NS)
above

Ethnicity

Disability

4Ps ID
Number

Name of Parents

Prepared by:

Noted :

__________________________________
Feeding Focal Person

_____________________________________
School Principal / Officer-in-Charge

Beneficiary of SBFP
in Previous Years
(yes or no)

Note: This form shall be prepared by the school, to be compiled by the DO, and for final compilation by the RO, for submission to DSWD-FO, copy furnished DepEd-HNC

SBFP Form 2
Department of Education
Region III

SCHOOL-BASED FEEDING PROGRAM (SBFP)

Division/Province: Tarlac Province
City/Municipality/Barangay: Gerona
Name of School/School District: Gerona North
Number of Undernourished School
Children by Grade Level

Nutritional Status at Start of Feeding

No. of
Severely
No. of
Total
Wasted
Wasted Beneficiaries No. of Ethnic Ben.

Ethnicity 4 Ps Beneficiaries

No. of 4 Ps Ben.

No. of Pupils who

are beneficiaries in
previous years

1. Kinder

13

13

2. Grade I

13

13

3. Grade II

25

25

4. Grade III

5. Grade IV

6. Grade V

27

27

7. Grade VI

15

15

107

107

11

13

Total
Prepared by:

Remarks

Noted by:

VIRGINIA N. DAGUIO

TEDDY M. JOSON

Feeding Focal Person

Principal II

Note: This form shall be prepared by the school, to be compiled by the DO, and for final compilation by the RO, for submission to DSWD-FO, copy furnished DepEdHNC

SBFP Form 3
Department of Education
Region III

SCHOOL-BASED FEEDING PROGRAM (SBFP)

Division/Province: Tarlac Province
School District/City/ Municipality : Gerona North

Name of Schools

Name of District
Name of Barangay
Supervisors/
School Principal or OICs

BEIS ID No.

School Address

Gabaldon E/S

106450

Poblacion #3, Gerona, Tarlac

Poblacion #3

Richard Melchor

Gerona North Central E/S

106451

Poblacion #3, Gerona, Tarlac

Poblacion #3

Teddy Joson

Prepared by:

Contact Number

Total
Beneficiaries
107

9477511786

Noted by:

VIRGINIA N. DAGUIO

TEDDY M. JOSON

Feeding Focal Person

Principal II

Note: This form shall be prepared by the DO, for final consolidation by the RO, for submission to DSWD-FO, copy furnished DepEd-HNC

107

SBFP Form 4
SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________
District ___________________________

NAME OF PUPIL

4Ps
Beneficiary
Beneficiary
of Previous
(y or n)
SBFP
(y or n)

School: _____________________________________
Grade: __________ Section _____________________

ACTUAL FEEDING

PRE FEEDING
Age

Birth
Date

Sex

Ht

Nutritional Status
Wt
Date

cm

kg

Taken

NS

Deworming
( ) or Date
(X) Taken 1

9 10 11 12 13 14 15 16 17 18 19 20

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
TOTAL:

Prepared by:
LEGEND
____________________________
Feeding Teacher / School Nurse

A. Nutritional Status
For 6-19 y.o

For below 6 y.o

B. Deworming

D. Actual Feeding

SW - Severely wasted

SU - Severely underweight

( x ) - not dewormed

( ) - Present, served

W - Wasted

U - Underweight

( ) - dewormed

( A ) - Absent, not served

N - Normal

N - Normal

Ow - Overwieght

Ow - Overwieght

( ) - Present, served twice

O - Obese

Note: This form shall be prepared by the school to be consolidated using SBFP Form 5

Page 5

SBFP Form 4
SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________
District ___________________________

School: _____________________________________
Grade: __________ Section _____________________

ACTUAL FEEDING
NAME OF PUPIL
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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
TOTAL:

D. Actual Feeding
( ) - Present, served
( A ) - Absent, not served
( ) - Present, served twice

page 2

SBFP Form 4
SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________
District ___________________________

School: _____________________________________
Grade: __________ Section _____________________

ACTUAL FEEDING
NAME OF PUPIL
61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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
TOTAL:

D. Actual Feeding
( ) - Present, served
( A ) - Absent, not served
( ) - Present, served twice

page 3

SBFP Form 4
SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________
District ___________________________

School: _____________________________________
Grade: __________ Section _____________________

ACTUAL FEEDING

POST FEEDING

101 102 ## 104 105 ## ## ## ## ## ## 112 113 114 115 116 117 118 119 120

Nutritional Status
Ht
Wt Date
cm
kg Taken NS

NAME OF PUPIL

ATTENDANCE
Days
Feeding
Percentage
Days
Present
(A)

(B)

(A/B)*100

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
TOTAL:

AVERAGE:

D. Actual Feeding
( ) - Present, served
( A ) - Absent, not served
( ) - Present, served twice

page 4

SBFP Form 5
SCHOOL-BASED FEEDING PROGRAM

CONSOLIDATED NUTRITIONAL STATUS AND ATTENDANCE REPORT

Region: _______
Division/District: ________________________
School: ________________________________
BEIS ID No.: ___________________________
GRADES AND SECTIONS

No. of Pupils
Dewormed

NUTRITIONAL STATUS
SW/SU

W/U

BEFORE
N
Ow

Ob

Total

SW/SU

W/U

AFTER
N
Ow

Total

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTAL

AVERAGE:

Legend:
For 6-19 y.o
SW - Severely Wasted
W - Wasted
N - Normal
Ow - Overweight
O - Obese

For below 6 y.o

SU - Severely Underweight
U - Underweight
N - Normal
Ow - Overweight

Prepared by:
_____________________________
Classroom Adviser / School Nurse

Noted by:

Note: This form shall be prepared by the school using the data from SBFP Form 4.

___________________________
School Head

PERCENTAGE
ATTENDANCE