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    WIFA Forms

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    Doc Alex
    This document appears to be a form for tracking the administration of iron-folic acid supplements to students in Bangladesh at the classroom, school, district, division, and regional levels over multiple rounds and months. It includes spaces to record student enrollment numbers, the number of female students, consent for the supplements, and dates of administration so compliance with the supplementation program can be monitored and reported.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    WIFA Forms

    Uploaded by

    Doc Alex
    625 views12 pages
    This document appears to be a form for tracking the administration of iron-folic acid supplements to students in Bangladesh at the classroom, school, district, division, and regional levels over multiple rounds and months. It includes spaces to record student enrollment numbers, the number of female students, consent for the supplements, and dates of administration so compliance with the supplementation program can be monitored and reported.

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    wifa form

    Original Title

    Copy of WIFA Forms

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    This document appears to be a form for tracking the administration of iron-folic acid supplements to students in Bangladesh at the classroom, school, district, division, and regional levels over multiple rounds and months. It includes spaces to record student enrollment numbers, the number of female students, consent for the supplements, and dates of administration so compliance with the supplementation program can be monitored and reported.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    625 views12 pages

    WIFA Forms

    Uploaded by

    Doc Alex
    This document appears to be a form for tracking the administration of iron-folic acid supplements to students in Bangladesh at the classroom, school, district, division, and regional levels over multiple rounds and months. It includes spaces to record student enrollment numbers, the number of female students, consent for the supplements, and dates of administration so compliance with the supplementation program can be monitored and reported.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 12

    Form 1 - Classroom Level

    School-based Weekly Iron Folic Acid (WIFA) Supplementation

    Region: _______________________ Division : Date: School Year: __________


    School ID: ____________________ Name of School:
    Grade Level/Section: _____________ No. of Students Enrolled: _________ No. of Female Learners: ________ Address: __________________________

    Provided With Iron Folic Acid Supplements


    Consent* 1st Round 2nd Round
    LRN NAME OF LEARNER July August September January February
    W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3
    Y N
    (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date) (date)
    *Consent given Administered by: Noted by:

    Class Adviser Date Grade Level Teacher Date


    Annex A1

    _____________________________

    und
    ary March REMARKS
    W4 W1 W2 W3 W4
    (date) (date) (date) (date) (date)
    Form 2a–Classrooml Level Annex A2

    School-based Weekly Iron Folic Acid (WIFA) Supplementation


    Round 1 Round 2

    Grade Level 7 8 9 10 ALS

    Region: _______________________ Division : ______________________________ Date: _______________ School Year: _______________

    School ID: _________ Name of School: _________________________________ Address: _______________________________________________

    Enrollment Given WIFA Supplements Not Given WIFA Supp. Remarks

    Section Total No. of Total No. of (Reasons why WIFA


    Enrolled Female Number % Number % is not given)
    Learners Learners

    Administered by: Noted by:

    Class Adviser Grade Level Teacher

    Date: _______________ Date: _______________


    Form 2a
    Form 2b – School Level Annex A2a

    School-based Weekly Iron Folic Acid (WIFA) Supplementation


    Round 1 Round 2

    Grade Level 7 8 9 10 ALS

    Region: _______________________ Division : ______________________________ Date: _______________ School Year: _____________

    School ID: _________ Name of School: _________________________________ Address: _____________________________________________

    Enrollment Given WIFA Supplements Not Given WIFA Supp. Remarks

    Section Total No. of Total No. of (Reasons why WIFA


    Enrolled Female Number % Number % is not given)
    Learners Learners

    7
    8
    9
    10
    ALS

    TOTAL

    Submitted by: Noted by:

    School Principal District Supervisor


    Date: _______________ Date: _______________

    Validated By:
    Form School Level School Nurse
    Form 3– District Level Annex A3

    School-based Weekly Iron Folic Acid (WIFA) Supplementation


    Round 1 Round 2

    Grade Level 7 8 9 10 ALS

    School Year: __________________


    Region: _____________________Division : _________________________________ District: ______________________

    Enrollment Given WIFA Supp. Not Given WIFA Supp. Remarks

    School ID School Total No. of Total No. of (Reasons why


    Enrolled Female Number % Number % WIFA is not
    Learners Learners given)

    1)
    2)
    3)
    4)
    5)
    6)
    7)
    8)
    9)
    10)
    Submitted by: Approved by:

    District Supervisor
    Date: _____ Validated By: Date: _______________
    School Nurse
    Form 4 - Division level Annex A5

    School-based Weekly Iron Folic Acid (WIFA) Supplementation


    Round 1 Round 2
    Grade Level 7 8 9 10 ALS

    Region: ____________
    Division: ________________
    Enrolment
    Given WIFA
    Given WIFA Supp. Not Given WIFA
    District Total No. of Total No. of Remarks
    Enrolled Female Number % Number % (Reasons why WIFA is not given)
    Learners Learners

    Submitted by: Approved by:

    _______________________________________
    Schools Division Supervisor/ Superintendent
    Date Accomplished: ______________________

    Validated by:

    Division Nurse In-Charge


    Form 5– Regional Level Annex A6

    School-based Weekly Iron Folic Acid (WIFA) Supplementation


    Round 1 Round 2
    Grade Level 7 8 9 10 ALS

    Region: __________________

    Enrolment Given WIFA Supplementation Not Given WIFA


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

    Prepared by: Approved by: Noted by:

    ______________________________
    WIFA Focal Person Director (BLSSD) HSD
    Date Accomplished: Date Accomplished: Date Accomplished:

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