DRAFT

Annex
A1

Form 1 – Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: I Division : Urdaneta City Date: November 10, 2017 School Year: 2017-2018

School ID: 300405 Name of School: Lananpin National High School Address: Pinmaludpod, Urdaneta City

Grade Level/Section: _______________________ Number of Students Enrolled _____________________ Number of Female Learners ___________________

Round 1 Round 2

LRN Consent Provided With Iron Folic Acid Supplements REMARKS

With Without Month of ___________ Month of ___________ Month of ____________
Name of Consent Consent W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Indicat Indicat Indicat Indica
Learner e Indicate Indicate Indicate e Indicate Indicate Indicate e Indicate te Indicate
date date date date date date date date date date date date

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
Administered by: Noted by:

___________________________________ ________________________________________
Class Adviser Grade Level Chair

Date: _________________________ Date: ___________________________________

 DRAFT
Annex A2

Form 2– School Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: I Division : Urdaneta City Date: November 14, 2017 School Year: 2017-2018

School ID: 300405 Name of School: LANANPIN NATIONAL HIGH SCHOOL Address:Pinmaludpod, Urdaneta City

Round 1 Round 2

Grade Level Enrollment Given WIFA Not Given WIFA

Supplements
Remarks
(Reasons why WIFA
Total No. of Enrolled Total No. of Female Number % Number % is not given)
Students Students

Grade 7

Grade 8

Grade 9

Grade 10
ALS

TOTAL
Submitted by: Noted by
_______________________ ____________________________
School Principal District Supervisor
Date Accomplished: ___________________
Validated By: ___________________
 DRAFT
School Nurse

Annex A3

Form 3– District Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 Grade Level 7 8 9 10 ALS School Year: ______________________

Region: ____________ Division: ________________ District: _______________

School
ID Name of School Enrolment Given WIFA Not Given WIFA
Remarks
(Reasons why
Total No. of Total No. of Number % Number % WIFA is not
Enrolled Female given)
Students Students

1
2
3
4
5
6
7
8
9
10
TOTAL
Submitted by: __________________________ Approved by: _____________________________
District Supervisor
Date Accomplished ___________________________
Validated by: ___________________________
 DRAFT
District School Nurse
Annex A4

Form 4– Division Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 School Year: ______________________

Region: ____________ Division: ________________

Enrolment Given WIFA Supplementation Not Given WIFA Remarks

Given WIFA (Reasons why
District WIFA is not given)

Total No. of Total No. of Number % Number %

Enrolled Female
Students Students
7 8 9 10 7 8 9 10 7 8 9 10 7 8 9 1 7 8 9 10 7 8 9 1
0 0
1
2
3
4
5
6
TOTAL
Submitted by: __________________________ Approved by: _____________________________
Schools Division Supervisor/ Superintendent
Date Accomplished:_______________________
Validated by: ____________________________
Division Nurse In-Charge
 DRAFT
Annex A5

Form 5– Regional Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 School Year: ______________________

Region: ____________

Remarks
Enrolment Given WIFA Not Given WIFA (Reasons why
Supplementation WIFA is not given)
Division

Total No. of Total No. of Number % Number %

Enrolled Students Female Students
1 7 8 9 10 7 8 9 10 7 8 9 1 7 8 9 1 7 8 9 1 7 8 9 1
0 0 0 0
2
3
4
5
6
7
8
TOTAL

Prepared by: __________________________ Approved by: _____________________________

WIFA Focal Person Regional Director
Date Accomplished:_______________________
Noted By: ____________________