deworming-report-Blank-form-July-2025.docx

forms

1. Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
Larena, Siquijor
PSDS Recording Form for the Control of Soil-Transmitted Helminthiasis:
Soil-Transmitted Helminthiasis: Albendazole (ALB)for 5-18 years old
Region:VII District:
Division: Siquijor Enrolment:
School: Date Given:
Grade Level and Section:
Age Bracket
Gender No. of Children EnrolledNo. of Children Dewormed
Remarks
Male Female 4 Ps Non 4Ps Total 4Ps Non 4Ps Total
5-12 yrs. old
13-18 yrs..old
19 yrs old and
above
Total
Prepared by: Date Accomplished: _______________________
_________________________
School Clinic Teacher

Noted by:
______________________
School Head

2. Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
Larena, Siquijor
PSDS Recording Form for the Control of Soil-Transmitted Helminthiasis:
Soil-Transmitted Helminthiasis: Albendazole (ALB)for 5-18 years old
Region:VII District: San Juan
Division: Siquijor Enrolment:
School: Date Given:P
Grade Level and Section
Grade Level
No. of Children Enrolled No. of Children Dewormed
Variance Remarks4Ps Non 4Ps Total 4Ps Non 4Ps Total
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Total
Prepared by: Date Accomplished: _______________________
_________________________
School Clinic Teacher
Noted by:
_______________________
School Head

3. Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
Larena, Siquijor
PSDS Recording Form for the Control of Soil-Transmitted Helminthiasis:
Soil-Transmitted Helminthiasis: Albendazole (ALB)for 5-18 years old
Region:VII District: San Juan
Division: Siquijor Enrolment:
School: Date Given:P
Grade Level and Section
Grade Level
Gender Total
Population
No. of Children Enrolled No. of Children Dewormed
Variance RemarksMale Female 4Ps Non 4Ps Total 4Ps Non 4PsTotal
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Total
Prepared by: Date Accomplished: _______________________
_________________________
School Clinic Teacher
Noted by:
_______________________
School Head

4. Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
Larena, Siquijor
PSDS Recording Form for the Control of Soil-Transmitted Helminthiasis:
Soil-Transmitted Helminthiasis: Albendazole (ALB)for 5-18 years old
Region:VII District: San Juan
Division: Siquijor Enrolment:
School: Date Given:P
Grade Level and Section
Grade Level
Gender Total
Population
No. of Children Enrolled No. of Children Dewormed
Variance RemarksMale Female 4Ps Non 4Ps Total 4Ps Non 4PsTotal
Total
Prepared by: Date Accomplished: _______________________
_________________________
School Clinic Teacher
Noted by:
_______________________
School Head