Republic of the Philippines

Department of Education
Region IV - A CALABARZON
Form 2 - School Level (Secondary)
National School Deworming Month (NSDM) Round 1
June 27 , 2019
Month Day Year
District / Name of School: Brgy.Longos SHS

No. of Children Dewormed No. of Children NOT Dewormed

Consented to Refused
Precautionary measure Adverse Event
Deworming (as Deworming (as No consent
Grade Enrolment indicated in indicated in (Seriously ill, with abdominal pain, diarrhea, Reported
TOTAL 4Ps form (type and no)
4Ps Non-4Ps consent form) consent form) has previous sensitivity with deworming drug
& Non-4Ps returned
"Annex B" MDAP Guide #1 page 14

Grade 7 117 30 13 43 43 74 0 0 0

Grade 8 94 17 12 29 29 65 0 0 0

Grade 9 123 27 1 28 28 95 0 0 0

Grade 10 98 26 15 41 41 57 0 0 0

TOTAL
(7-10) 432 100 41 141 141 291 0 0 0

Grade 11 79 28 28 56 56 23 0 0 0

Grade 12 86 24 11 35 35 51 0 0 0
TOTAL
(11-12) 165 52 39 91 91 74 0 0 0
SPED 0 0 0 0 0 0 0 0
ALS 0 0 0 0 0 0 0 0 0
Grand Total 597 152 80 232 232 365 0
Accomplished by: N O T E D:

____________________________ _________________________________________
Deworming Coordinator School Head
Date Accomplished: __________________
 % Dewormed
(total dewormed /
enrollment)

36.75

30.85

22.76

41.84

32.64

70.89

40.70

55.15 0

38.86
__________