Form 1 - Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: 1 Division: SDO ! Pangasinan Date : ________________________

School ID : 300163 Name of School: BANAOANG NATIONAL HIGH SCHOOL
Grade Level : Number of Students Enrolled:
Round 1 Round 2

Consent Provided With Iron Folic Acid Supplements

LRN Name of Learner Month of January-February Month of February-March

With Without
Consent Consent W1 W2 W3 W4 W1 W2 W3 W4
Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date
Administered by: Noted by:

Class Adviser Grade Level Chair

Date: APRIL 3, 2018 Date:
 Annex A1

ion

School Year :
Address: BANAOANG, STA. BARBARA, PANGASINAN
Number of Female Learners:

h Iron Folic Acid Supplements

Month of March - April
W1 W2 W3 W4 Remarks
Indicate Date Indicate Date Indicate Date Indicate Date
Form 1 - Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: 1 Division: SDO ! Pangasinan Date : ________________________

School ID : 300163 Name of School: BANAOANG NATIONAL HIGH SCHOOL
Grade Level : 12-Cookery Number of Students Enrolled:
Round 1 Round 2

Consent Provided With Iron Folic Acid Su

Month of August-September Month of September-October
LRN Name of Learner With Without
Consent Consent W1 W2 W3 W4 W1 W2 W3
Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date

101639060029 CERVANTES, Freda Fernandez 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

101639060033 DAVID, Jenny Rose Fernandez 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

300242100041 FERNANDEZ, Elizabeth Agustin

101639060043 FERNANDEZ, Jeralyn Hernandez

300163110071 FRANCISCO, Krizia Mae Barcenas 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

101648060043 OLAER, Marjorie Pascua 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

101648060045 ORIS, Abegail Marquez 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

101646050042 SISON, Angelica Santiago 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

101639060099 SORIANO, Jenifer Solomon 8-Aug-18 15-Aug-18 22-Aug-18 29-Aug-18 5-Sep-18 12-Sep-18 19-Sep-18

101639060100 SOTTO, Rina Mea Najera

101650060028 TUMAGCAO, Juvy Luna

Administered by: Noted by:

MARY ANN E. PALAGANAS
Class Adviser Grade Level Chair
Date: Date:
 Annex A1

ekly Iron Folic Acid (WIFA) Supplementation

Date : ________________________ School Year : 2018-2019

Address: BANAOANG, STA. BARBARA, PANGASINAN
Number of Female Learners: 11

Provided With Iron Folic Acid Supplements

Month of September-October Month of October-November
W4 W1 W2 W3 W4 Remarks
Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date

26-Sep-18 4-Oct-18

26-Sep-18 4-Oct-18

26-Sep-18 4-Oct-18

26-Sep-18 4-Oct-18

26-Sep-18 4-Oct-18

26-Sep-18 4-Oct-18

26-Sep-18 4-Oct-18
Form 1 - Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: 1 Division: SDO 1 Pangasinan Date : March 26,2019

School ID : 300163 Name of School: BANAOANG NATIONAL HIGH SCHOOL
Grade Level : 11-CSS Number of Students Enrolled:
Round 2

Consent Provided With Iron Folic Acid Su

Month of January-February Month of February-March
LRN Name of Learner With Without
Consent Consent W1 W2 W3 W4 W1 W2 W3
Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date

101640070003 Ballesteros, Annabelle Manait 21-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101640070005 Ballesteros, Jelyn Sambrano 22-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

300163090043 Dadacay, Joyce Carolyn Cera 22-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101645070008 Dela Cruz, Abegail Cabison 24-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101639070052 Desalit, Vangeline Pascua 25-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101639070062 Generalao, Jessica Nejal 26-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101648070046 Mandalunes, Jonaline Ramos 27-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101650070021 Manlongat, Lyn Soriano 28-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101639070082 Montemayor, Via May Salazar 29-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101640070023 Ofilada, Joemalyn Ballesteros 30-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101639070089 Osian, Judith Main 31-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101639070102 Placido, Bermily Soriano 31-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101652070007 Rosario ShairaJoy Sanchez 31-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

101650120005 Zamora, Jo Ann Manalo 31-Jan-19 28-Jan-19 4-Feb-19 11-Feb-19 18-Feb-19 25-Feb-19 4-Mar-19

Administered by: DAISY MARIE M. ALBA Noted by: RICHIE S. CAYABYAB

Class Adviser Grade Level Chair
Date: 26-Mar-19 Date: 26-Mar-19
 Annex A1

ekly Iron Folic Acid (WIFA) Supplementation

Date : March 26,2019 School Year : 2018-2019

Address: BANAOANG, STA. BARBARA, PANGASINAN
Number of Female Learners: 14

Provided With Iron Folic Acid Supplements

Month of February-March Month of March-April
W4 W1 W2 W3 W4 Remarks
Indicate Date Indicate Date Indicate Date Indicate Date Indicate Date

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

11-Mar-19 18-Mar-19 25-Mar-19 1-Aprl-19 8-Aprl-19

Form 2 - School Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: 1 Division: SDO ! Pangasinan Date : NOVEMBER 14, 2017 School Year : 2017-2018
School ID : 300163 Name of School: BANAOANG NATIONAL HIGH SCHOOL Address: Banaoang, Sta. Barbara, Pangasinan
Grade Level : ____________________ Number of Students Enrolled: 499 Number of Female Learners: 289
Round 1 x Round 2

Enrollment Given WIFA Supplements Not Given WIFA

Grade Level
Total No. of Enrolled Total No. of Enrolled
Students Students(FEMALE) Number % Number %

Submitted by:
Noted by:
Principal/School Head _________________________________________
 District Supervisor
Date Accomplished:

Validated by: ________________________________________________

 Annex A2

Supplementation

Year : 2017-2018
s: Banaoang, Sta. Barbara, Pangasinan
r of Female Learners: 289

Remarks (Reasons why WIFA is not

given)

___________________________________
District Supervisor
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: 2017-18

Region : 1 Division: SDO 1 Pangasinan District: ___________

Enrollment Given WIFA Supplements Not Given WIFA

School ID Name of School Remarks (Reasons why

WIFA is not given)
Total No. Of Total No. Of Number % Number %
Enrolled Enrolled
Students Students

Submitted by: ________________________________________

 Approved by: ____________________________________
Date Accomplished : ___________________________________

Validated by: _________________________________________

 Annex A3

School Year: 2017-18

District: ___________

ks (Reasons why
A is not given)
Form 4 - Division Level

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Round 1 Round 2 School Year : 2017-2018

Region : 1 Division: SDO 1 Pangasinan

Enrolment Given WIFA Given WIFA Supplements

Not Given WIFA
District Total No. of Enrolled Total No. of Enrolled Number % Number %
Students Students
7 8 9 10 7 8 9 10 7 8 9 10 7 8 9 10 7 8 9 10 7 8 9
Submitted by: __________________________________________
Date Accomplished: ____________________________________
Validated by: __________________________________________
Division Nurse -in-Charge
Approved by:
______________________________________
School Division Supervisor / Superintendent
 Annex A4

Remarks (Reasons
% why WIFA is not
given)
10