2018 SHD Form 2

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City

SCHOOL HEALTH EXAMINATION CARD

Name: School ID:
Last First Middle
LRN:
Date of Birth: Region:
Month Day Year
Birthplace: Division:
Parent/Guardian: Telephone No.:
Address:

Kinder/ Grade 1/ Grade 2/ Grade 3/ Grade 4/ Grade 5/ Grade 6/ Grade 7/ Grade 8/ Grade 9/ Grade 10/ Grade 11/ Grade 12/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings
Date of Examination
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/Wt-for-Age)
Nutritional Status (NS) (Height-for-Age)
Vision Screening using appropriate chart
Auditory Screening (Tuning Fork)
Skin/ Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Iron Supplementation (√ or X)
Deworming (√ or X)
Immunization (Specify what kind)
SBFP Beneficiary (√ or X)
4Ps Beneficiary (√ or X)
Menarche (√ the Start)
Others, specify
Examined by:
LEGEND:
Vision/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Lungs/Heart Abdomen Deformities
Screening
a. Normal a. Passed a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Weight
b. Wasted/ b. Failed b. Presence of Lice b. Stye b. Enlarged tonsils b. Rales b. Distended b. Congenital
Underweight (Specify)
c. Severely c. Redness of Skin c. Eye Redness c. Presence of lesions d. Wheeze c. Abdominal Pain
Wasted/Underwt

d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed pharynx e. Murmur d. Tenderness

e. Obese e. Flaky Skin E. Pale Conjunctiva e. Enlarged lymphnodes h. Irregular heart rate e. Dysmenorrhea

f. Normal Height f. Impetigo/ f. Ear discharge f. Others , specify i. Others, f. Others, Specify
boil specify
g. Stunted g. Hematoma g. Impacted cerumen

h. Severely h. Bruises/ Injuries h. Mucus discharge

Stunted
i. Tall i. Itchiness i. Nose Bleeding
(Epistaxis)
j. Skin Lessions j. Eye dischrage

k. Acne/Pimple k. Matted Eyelashes

l. Others , specify
2018 SHD Form 2
Note: Use Letter to record ailments and Place X if not examined
2018 SHD Form 2

INTERVENTION/TREATMENT RECORD

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

SCHOOL ORAL HEALTH EXAMINATION CARD

KINDER S.Y. GRADE 1 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 2 S.Y. GRADE 3 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

2
 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City

SCHOOL ORAL HEALTH EXAMINATION CARD

Full Name: School ID:

Last Name First Name Middle Name
LRN:
Date of Birth: Region:
Month Day Year
Birthplace: Division:
Parent/Guardian: Contact No.:
Address:

KINDER School Year: GRADE 1 School Year:

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 2 School Year: GRADE 3 School Year:

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 4 School Year GRADE 5 School Year

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH
 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

 GRADE 6 School Year: ORAL HEALTH CONDITION

1 2 3 4 5 6
Kinder 7 8 9 1 1 1

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Gingivitis

TEMPORARY TEETH Periodontal Disease
Malocclussion
Supernumerary teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Retained decidous teeth
PERMANENT TEETH

Decubital ulcer
Calculus
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Cleft lip / palate
Root fragment
Fluorosis
TEMPORARY TEETH Others, Specify
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

TEMPORARY TEETH dft index PERMANENT TEETH

1 2 3 4 5 6
Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder 7 8 9 1 1 1

No. T / decayed No. T / decayed

No. T / filled No. T / Missing
Total d.f.t. No. T. / Filled
For Extraction Total D.M.F.T.
For Filling For Extraction
Total Sound teeth For Filling
Total Sound teeth

SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent tooth FB - Fixed Bridge
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant CD - Complete Denture
RF - Root fragment JC - Jacket Crown GI - Glass Ionomer
M - Missing tooth P - Pontic CO - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AM - Amalgan
recurrence of decay

INTERVENTION/TREATMENT RECORD

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION
Pasig City

SCHOOL ORAL HEALTH EXAMINATION CARD

Full Name: School ID:

Last Name First Name Middle Name
LRN:
Date of Birth: Region:
Month Day Year
Birthplace: Division:
Parent/Guardian: Contact No.:
Address:

GRADE 7 School Year: GRADE 8 School Year:

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 9 School Year: GRADE 10 School Year:

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 11 School Year GRADE 12 School Year

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH
 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

 ORAL HEALTH CONDITION

1 2 3 4 5 6
Kinder 7 8 9 1 1 1

Gingivitis
Periodontal Disease
Malocclussion
Supernumerary teeth
Retained decidous teeth
Decubital ulcer
Calculus
Cleft lip / palate
Root fragment
Fluorosis
Others, Specify

TEMPORARY TEETH dft index PERMANENT TEETH

1 2 3 4 5 6
Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder 7 8 9 1 1 1

No. T / decayed No. T / decayed

No. T / filled No. T / Missing
Total d.f.t. No. T. / Filled
For Extraction Total D.M.F.T.
For Filling For Extraction
Total Sound teeth For Filling
Total Sound teeth

SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent tooth FB - Fixed Bridge
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant CD - Complete Denture
RF - Root fragment JC - Jacket Crown GI - Glass Ionomer
M - Missing tooth P - Pontic CO - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AM - Amalgan
recurrence of decay

INTERVENTION/TREATMENT RECORD

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

 Appendix 11

TEACHER'S HEALTH CARD

Date:
Name: Date of Birth: Age: Gender: M F
School/District/Division: Civil Status S M W S
Position/Designation: Years in Service:
First Year in Service:

Family History: (pls. check) Y N Specify Relationship

Hypertension [ ] [ ]
Cardiovascular Disease [ ] [ ]
Diabetes Mellitus [ ] [ ]
Kidney Disease [ ] [ ]
Cancer [ ] [ ]
Asthma [ ] [ ]
Allergy [ ] [ ]
Other Remarks:

Past Medical History: (check)

Y N Y N
Hypertension [ ] [ ] Tuberculosis [ ] [ ]
Asthma [ ] [ ] Surgical Operations (pls. specify) [ ] [ ]
Diabetes Mellitus [ ] [ ] Yellowish discoloration of skin/sclera [ ] [ ]
Cardiovascular Disease [ ] [ ] Last hospitalization (reason) [ ] [ ]
Allergy (pls. specify) Other (pls. specify)
Last Taken Date Result Date Result
CXR/Sputum Result: Drug Testing: Others specify
ECG Neuropsychiatric exam:
Urinalysis Blood Typing:

Social History
 Appendix 11

Smoking Y N Age started: Sticks/packs per day: Packs per year:

Alcohol Y N How often: Food preference:

OB Gyn History (pls. encircle) (Female Teachers)

Menarche: Cycle Duration
Parity: F P A L
Papsmear don: Y N if YES, When:
Self Breast examination done: Y N
Mass noted: Y N Specify where
For Male personnel: Digital rectal examination done: Y N Date examined:
Result:

Present Health Status (pls. check) Y N Y N

Cough 2wks 1 month longer
Dizziness [ ] [ ] Lumps [ ] [ ]
Dyspnea [ ] [ ] Painful urination [ ] [ ]
Chest/Back pain [ ] [ ] Poor/loss of hearing [ ] [ ]
Easy fatigability [ ] [ ] Syncope/fainting [ ] [ ]
Joint/extremity pains [ ] [ ] Convulsions [ ] [ ]
Blurring of vission [ ] [ ] Malaria [ ] [ ]
Wearing eyeglasses [ ] [ ] Goiter [ ] [ ]
Vaginal discharge/bleeding [ ] [ ] Anemia [ ] [ ]
Dental Status: (pls. specify) Others: Pls. specify)
Present Medication taken: (pls. specify)

Legend: CXR - Chest X-ray PTB - Pulmonary Tuberculosis

EXG - Electro Cardio Gram F - Full Term
Y - Yes P - Pre-mature
N - No A - Abortion
HPN - Hypertension L - Live Birth
CVD - Cardio Vascular Disease
DM - Diabetes Mellitus Interviewed by:
Date:
 Appendix 11

CONSULTATION AND TREATMENT RECORD:

Date/Signature of Treatment/
Chief Complaint Findings
Attending Physician Recommendation
Appendix 11
CS Form 86

HEALTH EXAMINATION RECORD

Name: Division: Department:
Date of Birth: Type of Work: Sex: Civil Status:

1 Date: Date: Date:

Height Height Height
Weight Weight Weight
2 Temperature:
3 Respiratory System:
Fluorography:
Sputum Analysis:
4 Circulatory System:
Blood Pressure:
Pulse:
Sitting: Agility Test: Sitting: Agility Test: Sitting: Agility Test:
5 Digestive System:
6 Genito-Urinary:
Urinalysis, etc.
7 Skin:
8 Locomotor System:
9 Nervous System:
10 Eyes: Conjuctivities, etc.:
Color Perception:
11 Vision:
With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: _________ With glasses: Far: __________ Near: _________
Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________ Without glasses: Far: __________ Near: _________
12 Nose:
13 Ear:
14 Hearing:
Right: Left: Right: Left: Right: Left:
15 Throat:
16 Teeth and Gums:
17 Immunization:
18 Remarks
19 Recommendation
20 Employee's Signature:
Employee's Name (Print):
21 Physician's Signature:
CS Form 86

Physician's Name (Print):

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region:
Division of:
DENTAL REFERRAL FORM

Patients Name:
Age:
Phone Number:

Dear Dr.:

I am referring to your office for:

Oral Prophylaxis

Restoration 18 17 16 15 14 13 12 11 21
47 47 46 45 44 43 42 41 31
Extraction

Other Procedures:

Note: (Example: Resto#16, Exo #46) If OUT is needed

Sincerely:

School Dentist

Kindly return Dental Slip

DENTAL TREATMENT RETURN SLIP

Dental Procedure done:

Oral Prophylaxis

Restoration

Extraction

Other Procedures:

Signature:
DENTIST'S NAME:
Lic. No.:
HNC Form 5

Republic of the Philippines

Department of Education
Region ____________________
Division of __________________________

REFERRAL SLIP

To Date
(Agency)
Address

This is to refer to you:

Name: Age: Sex:

Address/School: Grade:
Chief Complaint:

Impression:
Remarks:

Name and Signature

Designation

Note: To be detached from upper portion and sent back to the school.
Return Slip

Returned to
Name of Patient Date Referred
Chief Complaint
Findings
Action/Recommendations

Date Name & Signature

Designation
 Appendix 6
HNC NS Form 1
Republic of the Philippines
Department of Education
Region ___________________
Division of _____________________
______________________________________________
School Name/ID

RECORD OF DAILY TREATMENT

Chief
Date Name of Patient Grade Treatment Attended by Signature of Patient Remarks
Complaint

Name Designation
 Appendix 8

HNC NS Form 3
Republic of the Philippines
Department of Education
Region _______________________
Division of ____________________

ANNUAL HEALTH SERVICES ACCOMPLISHMENT REPORT

SY: ________________________

Name of School: School ID No.:

Total No. of Elem. Schools Visited

Total No. of Sec. Schools Visited

I. General Information
A. School Enrolment
1. Male
2. Female
B. No. of School Personnel
1. Teaching
Male
Female
2. Non-Teaching
Male
Female
II. Health Services
A. Health Appraisal
1. No. of Assessed:
a. Learners
b. Teachers
c. NTP
2. No. with Health Problems
a. Learners
b. Teachers
c. NTP
3. No. of Vision Screening (Learners)
B. Treatment Done
a. Learners
b. Teachers
c. NTP
 Appendix 8

C. No. of Pupils Dewormed

1st Round
2nd Round
D. No. of Pupils Given Iron Supplement
E. No. of Pupils Immunized (Specify vaccine given)
F. No. of consultation attended
1. Learners
2. Teachers
3. NTP
G. Referral (No. Referred to)
1. Physician
2. Dentist
3. Guidance
4. Other facilities
5. RHU/ District/ Provincial Hospital
III. Health Education
No. of Classes given health lectures:
A. No. of orientation training conducted to:
1. Learners
2. Teachers
3. Parents
4. Others (Specify)
B. No. of conferences/meeting with:
1. Teachers/ Adminstrators
2. Health officials
3. Learners
4. Parents
5. LGU/Barangay
6. NGO's/Stakeholders
C. Involvement as Resource Person/ Consultant/ Adviser/ Judge
1. Health Activities/ programs/ contests
2. Class Discussion
3. Health Clubs/ Organization
IV. School Community Activities for Health and Nutrition
A. PTA/ Homeroom Organization Meetings
B. Parent Education Seminar/ Workshop/Training
C. Home Visits Conducted
D. Hospital Visits made
 Appendix 8

V. Common Signs & Symptoms

A. Skin and Scalp
1. Presence of Lice (Pediculosis)
2. Redness of Skin
3. White Spots
4. Flaky Skin
5. Minor Injuries
6. Impetigo/Boil
7. Skin Lessions
8. Acne/Pimples
9. Itchiness
B. Eye and Ears
1. Matted eye lashes
2. Eye redness
3. Ocular misalignment (Squint)
4. Eye dischrge
5. Pale conjunctiva
6. Hordeolum
7. Ear discharge
8. Mucos discharge
9. Nose bleeding (epistaxis)
C. Mouth/ Neck / Throat
1. Presence of Lessions
2. Inflammed Pharynx
3. Enlarged tonsils
4. Enlarged lymphnodes
D. Heart and Lungs
1. Rates
2. Murmur
3. Irregular heart rate
4. Wheezes
E. Deformities
1. Acquired (Specify)
2. a. Acquired
 Appendix 8

F. Nutritional Status
a. Normal
b. Wasted
c. Severly Wasted
d. Obeese
e. Overweight
f. Stunted
g. Tall
G. Abdomen
1. Abdominal pain
2. Distended
3. Tenderness
4. Dysmenorrhea
H. Dental Service
1. Gingivitis
2. Periodontal Disease
3. Malocclussion
4. Supernumecoary Teeth
5. Retained decidous Teeth
6. Decubital Ulcer
7. Calculus
8. Cleff Lip/ Palate
9. Flourosis
10. Others / Specify
11. Total # of DMFT
12. Total # of dmft
I. Other Signs & Symptoms Noted:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 Appendix 8

VI. Remarks:

Prepared by: Noted by:

Name / Designation School Head

Date
 Appendix 9

HNC NS Form 4
Republic of the Philippines
Department of Education
Region _______________________
Division of ____________________

School Health Survey

Year _________

Name of School District:

Address School ID
Name of School Head Contact No.:

I. General Information

1. Enrollment:
Male Female Total
A. Elementary
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
SPED
Total
B. Junior HS
Grade 7
Grade 8
Grade 9
Grade 10
Senior HS
Grade 11
Grade 12
SPED
ALS Learners
Total

2. School Personnel

Male Female Total

Teaching
Non-Teaching
Total

3. Number of Drop-out due to:

Male Female Total

a. Illness
b. Poverty
 Appendix 9

c. Other reasons

II. Health Profile

1. Number Examined/Assessed: Male Female Total
a. Learners
b. Teachers
c. NTP
2. Found with:
a. Health Problems
b. Physical deformities/defects
1.
2.
3.
3 Treated
1.
2.
3.
4 Number dewormed
5 No. given Iron Supplement
6 Number referred to other facilities
7 Number referred to
a. Physicians
b. Dentist
c. Nurse
d. Guidance Counselors
e. Others

B. Ten Common Signs and Symptoms noted:

Learners Teaching & NTP

Signs & Symptoms No. of Cases Rank Signs & Symptoms No. of Cases Rank
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10

III. School Facilities

1. School site area sq. meters
2. Number of buildings
3. Number of classrooms
4. Health facilities
1. School Clinic
a. Area sq. meters
b. Location (Please check)
separate building
room within the building
within a classroom/room
 Appendix 9

c. Provision and maintenance (Please check)

toilet in the clinic
potable water supply
medicines
weighing scale (specify)
height stadiometer
medicine/treatment cabinet
examination table/bed
foot stool/receptacle
dental chair
potable water supply
working table
treatment records
clinic teacher/school nurseassigned
stock cabinet

2. School Toilet
a. Provision of gender sensitive type toilet
b. Number of seats/urinal
c. Provision of menstrual hygiene room
d. Availability of sanitary pad
3. Water supply and drinking water
a. Source
b. Certificate of Water analysis
4. Washing Facilities
a. Source
b. provision of handwashing soap
5. School Canteen
a. Sanitary Permit
b. Health Certificate of helpers
c. Compliance to DepEd Order No. 13, s. 2017

Remarks:

Accomplished by:

Name

Designation

Date of Survey
NOTE: to be accomplished once every 3 years