Form 3 District level

NATIONAL SCHOOL DEWORMING ACCOMPLISHMENT REPORT

DATE OF DEWORMING: _______________________

NO. SCHOOL ENROLMENT NO. OF LEARNERS DEWORMED NO. OF LEARNERS

NOT DEWORMED
DUE TO

4Ps Non-4Ps TOTAL 4Ps Non-4Ps TOTAL

Serious Medical
Consent not

(Specify)
returned

Refusal
Sickness /

Condition
Others
Parent
M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL

Accomplished by: Noted by:

District Nurse District Supervisor

Date Accomplished: _____________