SBFP Form 1

Department of Education
Region IV - B MIMAROPA

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

Division/Province: DIVISION OF CALAPAN CITY/ ORIENTAL MINDORO Name of Principal : MARIA TERESITA M. CORTEZ
City/ Municipality/Barangay : CALAPAN CITY / SAN ANTONIO Name of Feeding Focal Person : FATIMA T. GONZALES
Name of School / School District : SAN ANTONIO ES/ CALAPAN EAST

Date of
Grade BMI for
Date of Birth Weighing / Age in Participation in Beneficiary of
& Weigh Heigh 6 y.o. Nutritional
No. Name Sex
Secti
(MM/DD/YYY Measuring Years /
t (Kg) t (cm) and Status (NS)
4Ps Name of Parents SBFP in Previous
Y) (MM/DD/YYYY Months (yes or no) Years (yes or no)
on above
)

1 Ramos, Khien Jessty P. M I-B 3/23/2009 6/18/2015 6,2 15 111 12.1 SW No Elena Padua No
2 Villena, John Kiven R. M I-B 10/12/2009 6/18/2015 5,8 11 96 11.9 SW No Nio Jesus Villena No
3 Enriques, John Lorenz M II-A 4/23/2008 6/5/2015 7,1 16 115 12 SW Yes Evangeline Enriques Yes
4 Llaguno, Maria Lyka D. F II-A 10/14/2008 6/5/2015 6,7 15 119 10.15 SW Yes Celestial De Leon No
5 Esteleydes, Samuel D. M III-A 7/11/2007 6/19/2015 7,11 16 114 12.3 SW No Randy Esteleydes No
6 Marcial, Justine M III-A 6/16/2007 6/19/2015 8 15 110 12.3 SW Yes Emy Marcial Yes
7 Cagata, Shaina C. F IV-A 4/11/2006 6/18/2015 9,2 22 136 11.8 SW Yes Renalyn Cagata No
8 Masangkay, Janette Kristine P F IV-A 1/5/2005 6/18/2015 10,5 20 131 11.6 SW Yes Mary Antonette Perez Yes
9 Agustin, Allan Jr. L. M IV-C 3/16/2004 6/18/2015 11,3 19 121 12.9 SW Yes Jennifer Agustin No
10 Damayo, John Adrian P. M IV-C 5/17/2006 6/18/2015 9,1 19 123 12.5 SW Yes Annaliza Damayo Yes
11 Masangkay, Kerbelyn F. F IV-C 7/17/2006 6/18/2015 8,11 15 112 19.9 SW Yes Robelyn Masangkay No
12 Abella, Jhon Patrick J. M V-A 4/10/2004 6/17/2015 11,2 20 126 12.5 SW Yes Josephine Abella No
13 De Lara, Celina F V-A 7/3/2003 6/17/2015 11,11 20 127 12.4 SW Yes Marilyn De Lara No
14 Millas, Ma. Ann Pauline B. F V-B 5/28/2005 6/17/2015 10 17 118 12.2 SW Yes Antonina Millas Yes
15 Fernandez, Prince Charles E. M VI-A 10/10/2003 6/5/2015 11,7 22 132 12.6 SW Yes Cleofe Fernandez Yes

Prepared by: NOTED:

FATIMA T. GONZALES MARIA TERESITA M. CORTEZ

Feeding Focal Person
Principal III
SBFP Form 1
Department of Education
Region IV - B MIMAROPA

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

Division/Province: DIVISION OF CALAPAN CITY/ ORIENTAL MINDORO Name of Principal : MARIA TERESITA M. CORTEZ
City/ Municipality/Barangay : CALAPAN CITY / SAN ANTONIO Name of Feeding Focal Person : FATIMA T. GONZALES
Name of School / School District : SAN ANTONIO ES/ CALAPAN EAST

Grad Date of BMI Beneficiary of

Age in Weig Heig for 6 Nutritional Participation
e & Date of Birth Weighing / SBFP in
No. Name Sex (MM/DD/YYY Measuring Years / ht ht y.o. Status in 4Ps Name of Parents
Sect Y) (MM/DD/YYYY Months (Kg) (cm) and Previous Years
(NS) (yes or no)
ion ) above (yes or no)

1 Barrientos, Prince Santino L. M I-A 8/23/2009 6/18/2015 5,9 16 112 12.7 W Yes Rhodora Barrientos Yes
2 Serna, Carl R. M I-A 6/4/2009 6/18/2015 6 16 112 12.7 W Yes Hazel Serna No
3 Mayo, Ma. Christine F. F I-A 2/3/2009 6/18/2015 6, 4 13 102 12.4 W Yes Ma. Fe Mayo No
4 Mendoza, Cashopea Eczane F I-A 5/29/2009 6/18/2015 6 15 109 12.6 W Yes Betty Jean Mendoza Yes
5 Medullar, Raizelle Ann D. F I-A 1/18/2009 6/18/2015 6,5 15 109 12.6 W Yes Joana Medullar No
6 Santos, Maureen Claire G. F I-A 1/6/2009 6/18/2015 6,5 15 106 12.6 W Yes Lea Santoa Yes
7 Lino, Crystal Shaine C. F I-B 3/3/2009 6/18/2015 6,3 14 105 12.6 W Yes Veronica Lino Yes
8 Rosal, John Lloyd P. M II-A 2/8/2007 6/5/2015 8,3 16 111 12.9 W Yes Miriam Rosal No
9 Cajayon, Shem B. F II-A 12/26/2007 6/5/2015 7,5 16 116 11.8 W Yes Sharon Cajayon No
10 Canales, Jeslyn F II-A 2/15/2008 6/5/2015 7,3 16 113 12.5 W Yes Lorilyn Canales No
11 Enriquez, Marie Ceries Ellaine B. F II-A 2/16/2008 6/5/2015 7,3 16 114 12.3 W Yes Karen Enriquez No
12 Faeldo, Charmel M. F II-A 7/26/2008 6/5/2015 6,10 16 113 12.5 W No Madonna Faeldo Yes
13 Gacus, Geraldine N. F II-A 8/28/2008 6/5/2015 6,9 15 110 12.3 W No Rhoda Nidoy No
14 Maglinao, Justine M II-B 7/20/2008 6/5/2015 6,10 17 116 12.6 W Yes May Maglinao No
15 Blanco, Chanelle Kelly F II-B 2/5/2008 6/5/2015 6,10 15 109 12.6 W Yes Cristina Blanco No
16 Cruzado, Clarissa Joy F II-B 9/27/2008 6/5/2015 6,8 15 109 12.6 W Yes Leila Cruzado No
17 Masangkay, Jasmine Kay F II-B 9/24/2008 6/5/2015 6,8 15 112 11.9 W Yes Mary Antonette Perez Yes
18 Roxas, Rachelle F II-B 7/31/2008 6/5/2015 6,10 15 109 12.6 W Yes Nerilyn Roxas Yes

Prepared by: NOTED:

FATIMA T. GONZALES MARIA TERESITA M. CORTEZ

Feeding Focal Person Principal III
SBFP Form 2
Department of Education
Region ___

SCHOOL-BASED FEEDING PROGRAM (SBFP) LIST OF SCHOOLS

Division/Province: ______________________________________
School District/City/ Municipality : ____________________________

Name of District
Total
Supervisors/
Name of Schools BEIS ID No. School Address Name of Barangay Contact Number Beneficiari
School Principal
es
or OICs

Prepared by: Noted by:

SBFP DepED Focal Unit Chief

Note: This form shall be prepared by the DO, for final consolidation by the RO, for submission to DSWD-FO, copy furnished DepEd-HNC
SBFP Form 3
Department of Education
Region IV - B MIMAROPA

SCHOOL-BASED FEEDING PROGRAM (SBFP) SUMMARY OF BENEFICIARIES & START OF FEEDING

Division/Province: DIVISION OF CALAPAN CITY / ORIENTAL MINDORO
City/ Municipality/Barangay : CALAPAN CITY / SAN ANTONIO
Name of School / School District : SAN ANTONIO ES / CALAPAN EAST

Date of Start of Feeding: September 28, 2015

Nutritional Status at Start of Feeding No. of Pupils

Number of Undernourished who are
School Children by Grade No. of Total beneficiaries
Level Severely No. of Beneficiar No. of 4 Ps in previous
Wasted Wasted ies Beneficiaries years Remarks

1. Kinder 0 0 0 0 0

2. Grade I 2 7 9 7 0

3. Grade II 2 11 13 11 0

4. Grade III 2 0 2 2 0

5. Grade IV 5 0 5 5 0

6. Grade V 3 0 3 3 0

7. Grade VI 1 0 1 0 0

Total 15 18 33 28 0

Prepared by:
NOTED:

FATIMA T. GONZALES MARIA TERESITA M. CORTEZ

SBFP DepEd Focal Principal III

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 DepEd-HNC
 SBFP Form 4
SCHOOL-BASED FEEDING PROGRAM
RECORD OF DAILY FEEDING

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________

ACTUAL FEEDING
PRE FEEDING
4Ps
NAME OF PUPIL Beneficiary Beneficiary Nutritional Status Deworming
(y or n) of Previous Ht Wt Date
SBFP
Age Birth Sex ( ) or Date
NS
(y or n) Date cm kg Taken (X) Taken 1 2 3 4 5 6 7 8 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
____________________________ A. Nutritional Status
B. Deworming D. Actual Feeding
Feeding Teacher / School Nurse For 6-19 y.o For below 6 y.o
SW - Severely wasted SU - Severely underweight ( x ) - not dewormed ( ) - Present, served
W - Wasted U - Underweight ( ) - dewormed ( A ) - Absent, not served
N - Normal N - Normal ( ) - Present, served twice
Ow - Overwieght Ow - Overwieght
O - Obese

Page 6
Note: This form shall be prepared by the school to be consolidated using SBFP Form 5

Page 7
 SBFP Form 4

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ 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 ___________________________ School: _____________________________________
District ___________________________ 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 ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________

ACTUAL FEEDING POST FEEDING

ATTENDANCE
NAME OF PUPIL Nutritional Status Days Feeding
Percentage
Ht Wt Date Present Days
101 102 ### 104 105 ### ### ### ### ### 111 112 113 114 115 116 117 118 119 120 cm kg Taken NS (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
page 4