Deworming Masterlist Template

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Classroom Level Department of Education

(use separate sheet if necessary) Division of Bohol


Deworming Master List Form S.Y. 2021-2022

Name of School: Enrolment:


District: Male:
Grade Level & Section: Female:
Class Adviser: check if applicable Total
OCTOBER 2021
DOSE No. of
Contact Learners
Full Name of Pupil NAME OF PARENT/ No. of 4Ps BENEFICIARIES Dewormed
No. Signature of
(Last, First, MI) GUARDIAN parent/ Date Parent/
guardian 4Ps NON-4Ps 4Ps NON-4Ps
Received Guardian
M F M F M F M F

Prepared by: Noted by:

Class Adviser School Head

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