Form 1 – Classroom Level Annex A1

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: Division : Date: School Year:

School ID: _____________ Name of School: Address:
Grade Level/Section: ______________________ Number of Students Enrolled: Number of Female Learners: ______________
Round 1 Round 2

LRN Consent Provided With Iron Folic Acid Supplements REMARKS

Name of Learner

With Without Month of ___________ Month of ___________ Month of ____________

Consent Consent W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL
Administered by: Noted by:

Class Adviser Grade Level Chair

Date: Date:
 Form 1 – Classroom Level Annex A1

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: Division : Date: School Year:

School ID: _____________ Name of School: Address:
Grade Level/Section: ______________________ Number of Students Enrolled: Number of Female Learners: ______________
Round 1 Round 2

LRN Consent Provided With Iron Folic Acid Supplements REMARKS

Name of Learner

With Without Month of ___________ Month of ___________ Month of ____________

Consent Consent W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date

16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTAL
Administered by: Noted by:

Class Adviser Grade Level Chair

Date: Date:

Form 1 – Classroom Level Annex A1

School-based Weekly Iron Folic Acid (WIFA) Supplementation

Region: Division : Date: School Year:

School ID: _____________ Name of School: Address:
Grade Level/Section: ______________________ Number of Students Enrolled: Number of Female Learners: ______________
Round 1 Round 2

LRN Consent Provided With Iron Folic Acid Supplements REMARKS

Name of Learner

With Without Month of ___________ Month of ___________ Month of ____________

Consent Consent W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4
Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date Indicate date

31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
TOTAL
Administered by: Noted by:
 Class Adviser Grade Level Chair
Date: Date:
 Form 1 – Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supplemen

Round 1 Round 2 Grade 7 Grade 8 Grdae 9

Region: _______________________________Division : ______________________________ District : ________________

GRADE LEVEL /ENROLLMENT GIVEN WIFA NOT GIVEN WIFA

SUPPLEMENTS SUPPLEMENTS
TOTAL NUMBER TOTAL NUMBER NUMBER % NUMBER
OF ENROLLED OF FEMALE
STUDENTS STUDENTS
GRADE 7
GRADE 8
GRADE 9
GRADE 10
ALS

TOTAL
Submitted by:
Noted by:
School Principal
Date: District Super
Date:

Validated
 Annex A2

Acid (WIFA) Supplementation

Grade 10 ALS School Year ; _______________

strict : ________________________

NOT GIVEN WIFA REMARKS

SUPPLEMENTS ( Reason why WIFA not given)
%

District Supervisor
 Form 1 – Classroom Level

School-based Weekly Iron Folic Acid (WIFA) Supp

Region: Division :
School ID: _____________ Name of School:
Grade Level/Section: ______________________ Number of Students Enrolled:
Round 1 Round 2

SCHOOL ID NAME OF SCHOOL /ENROLLMENT GIVEN WIFA

SUPPLEMENTS
TOTAL NUMBER TOTAL NUMBER NUMBER %
OF ENROLLED OF FEMALE
STUDENTS STUDENTS
1
2
3
4
5
6
7
8
9
10
11
12
TOTAL
Submitted by:
Noted by:
District Nutrition Coordinator
Date:

Validated
 Annex A3

n Folic Acid (WIFA) Supplementation

Date: School Year:

Address:
Number of Female Learners: ______________

NOT GIVEN WIFA REMARKS

SUPPLEMENTS ( Reason why WIFA not given)
NUMBER %

oted by:

District Supervisor
Date:
___________