GOVERNMENT ELEMENTARY SCHOOL PROFILE , SY 2019-2020

All BEIS Forms Certified True and Correct by : School Head __________________ Validated by Planning Officer III (PRS-SGOD): ________________
Validated / Noted by :
Difference
Page (Division
TABLE BOX
# TITLE between Coordinator/Personnel)
last SY

1 SCHOOL INFORMATION Revised PRS SGOD & SDO

1 2 Table 1. LEARNERS DATA, SY 2019-2020 (As of June 30, 2019) Revised PRS SGOD
2 3 Table 2. LEARNERS AGE PROFILE, SY 2019-2020 (As of June 30, 2019) Revised PRS SGOD
3 4 Table 3. REPEATERS AGE PROFILE, SY 2019-2020 (As of June 30, 2019) Revised PRS SGOD
4 5 Table 4. AGE PROFILE OF LEARNERS WITH DISABILITIES (LWDs), SY 2019-2020 (As of June 30, 2019) Revised PRS SGOD
5 6 Table 5. LEARNERS DATA BY PROGRAM, SY 2019-2020 (As of June 30, 2019) Revised SPED
6 6 Table 6. GIFTED AND TALENTED LEARNERS DATA, SY 2019-2020 (As of June 30, 2019) Revised SPED
7 7 Table 7. AGE PROFILE OF GIFTED AND TALENTED LEARNERS, SY 2019-2020 (As of June 30, 2019) Revised SPED
8 8 Table 8. ENROLLMENT AND NUMBER OF CLASSES BY SHIFT, SY 2019-2020 (As of June 30, 2019) Revised SPED
1 8 Box 1. NUMBER OF CLASSES, SY 2019 -2020 (As of June 30, 2019) Revised SPED
9 9 Table 9. LEARNERS WITH DISABILITIES (NON-GRADED) DATA, SY 2019-2020 (As of June 30, 2019) Revised SPED
10 (Cont. of Table 9) Revised SPED
10 11 Table 10. LEARNERS WITH DISABILITIES (GRADED) DATA MAINSTREAMED IN REGULAR CLASS, SY 2019-2020 (As of June 30, 2019) Revised SPED
11 12 Table 11. LEARNERS WITH DISABILITIES (GRADED) DATA IN SELF-CONTAINED CLASS, SY 2019-2020 (As of June 30, 2019) Revised SPED
12 13 Table 12. LEARNERS WITH DISABILITIES (LWDs) UNDER THE HOMEBOUND AND HOSPITAL BOUND PROGRAM, SY 2019-2020 (As of June 30, 2019) Revised SPED
13 14 Table 13. NUMBER OF ASSISTIVE TECHNOLOGY AND ADAPTIVE DEVICES FOR LWDs, SY 2019-2020 (As of June 30, 2019) Revised SPED
14 15 Table 14. NUMBER OF EQUIPMENT AND TOOLS IN THE SCHOOL FOR LWDs, SY 2019-2020 (As of June 30, 2019) Revised SPED
15 16 Table 15. LEARNING RESOURCES NEEDED FOR THE LEARNERS WITH DISABILITIES (LWDs), SY 2019-2020 (As of June 30, 2019) NEW SPED
16 17 Table 16. LOCALLY-FUNDED TEACHERS WORKING IN THE SCHOOL BY FUNDING SOURCE, SY 2019-2020 (As of June 30, 2019) NEW HR
17 17 Table 17. LOCALLY-FUNDED TEACHERS WORKING IN THE SCHOOL WHO ARE QUALIFIED AND TRAINED, SY 2019-2020 (As of June 30, 2019) NEW HR / HRTD
18 17 Table 18. DEPARTMENT OF EDUCATION (DepEd) SUBSIDIZED CONTRACT OF SERVICE (COS) TEACHERS/ ASATIDZ HANDLING ALIVE CLASSES, SY 2019-2020 (As of June 30, 2019) NEW HR / DAC
19 18 Table 19. TEACHING RELATED AND NON-TEACHING PERSONNEL DATA (Nationally-funded), SY 2019-2020 (As of June 30, 2019) Revised HR
20 19 Table 20. TEACHING PERSONNEL DATA (Nationally-funded), SY 2019-2020 (As of June 30, 2019) Revised HR
21 20 Table 21. TEACHER ASSIGNMENTS (Nationally-funded teachers working in the school), SY 2019-2020 (As of June 30, 2019) Revised HR
22 20 Table 22. TEACHERS WHO RECEIVED TRAINING WHILE IN-SERVICE FROM JUNE 2018 TO JUNE 2019 (Nationally-funded teachers working in the school), SY 2019-2020 (As of June 30, 2019) NEW HR / HRTD
23 21 Table 23. TEACHERS WHO RECEIVED TRAINING ON INFORMATION AND COMMUNICATIONS TECHNOLOGY (ICT) FROM JUNE 2015 TO JUNE 2019 NEW HRTD
24 21 Table 24. TEACHERS WHO RECEIVED TRAINING ON PEDAGOGY FROM JUNE 2015 TO JUNE 2019 (Nationally-funded teachers working in the school), SY 2019-2020 (As of June 30, 2019) NEW HRTD
25 22 Table 25. NUMBER OF TEACHERS BY GRADE LEVEL (Nationally-funded teachers actually working in the school), SY 2019-2020 (As of June 30, 2019) Revised HR
26 22 Table 26. NUMBER OF TEACHERS BY TEACHING ASSIGNMENT IN GRADES 4 TO 6 (Nationally-funded teachers actually working in the school), SY 2019-2020 (As of June 30, 2019) Revised HR
27 23 Table 27. TEACHERS’ DATA HANDLING LEARNERS WITH DISABILITIES (LWDs) (Nationally-funded teachers only), SY 2019-2020 (As of June 30, 2019) Revised HR / SPED
28 24 Table 28. NUMBER OF TEACHERS BY HIGHEST EDUCATIONAL ATTAINMENT (Nationally-funded teachers only), SY 2019-2020 (As of June 30, 2019) Revised HR
2 24 Box 2. LEARNING ACTION CELL (LAC) SESSION, SY 2019-2020 Revised CID
3 24 Box 3. ACTION RESEARCH, SY 2019-2020 Revised SEPS_PRS SGOD
4 25 Box 4 . SCHOOL GOVERNMENT PROGRAM (SGP), SY 2019-2020 Revised YFD
5 25 Box 5 . SUPREME PUPILS GOVERNMENT (SPG) ACTIVITIES, SY 2019-2020 Revised YFD
6 25 Box 6. CAREER GUIDANCE PROGRAM, SY 2019-2020 Revised YFD
29 26 Table 29. NUMBER OF FUNCTIONAL COMPUTERS IN THE SCHOOL BY FUNDING SOURCE, SY 2019-2020 (As of June 30, 2019) Revised ITO
30 27 Table 30. NUMBER OF FUNCTIONAL ICT EQUIPMENT IN THE SCHOOL BY FUNDING SOURCE, SY 2019-2020 (As of June 30, 2019) Revised ITO
7 28 Box 7. DATA ON INTERNET CONNECTIVITY, SY 2019-2020 (As of June 30, 2019) Revised ITO
31 28 Table 31. AVERAGE MONTHLY EXPENSE (IN PESOS) OF INTERNET CONNECTION BY FUNDING SOURCE, SY 2019-2020 (As of June 30, 2019) Revised ITO
32 29 Table 32. MOOE ALLOCATION, UTILIZATION AND LIQUIDATION FROM JANUARY 2018 TO DECEMBER 2018 Revised Div. Accountant
8 29 Box 8. AVAILABILITY OF ELECTRICAL SUPPLY, SY 2019-2020 (As of June 30, 2019) Revised PFD/DIV ENGNR
9 30 Box 9. SCHOOL SITE DATA, SY 2019-2020 (As of June 30, 2019) Revised PFD/DIV ENGNR
31 (Cont. of Box 9) Revised PFD/DIV ENGNR
33 32 Table 33. TRAVEL DETAILS (ONE-WAY) FROM SCHOOL, SY 2019-2020 Revised PFD/DIV ENGNR
10 32 Box 10. SCHOOL LOCATION, SY 2019-2020 Revised PFD/DIV ENGNR
34 33 Table 34. HEALTH AND NUTRITION, SY 2019-2020 Revised SCH HEALTH
11 34 Box 11. SCHOOL CLINIC, SY 2019-2020 Revised SCH HEALTH
12 35 Box 12. AVAILABILITY OF WATER SUPPLY, SY 2019-2020 (As of June 30, 2019) Revised SCH HEALTH
35 35 Table 35. NUMBER OF EXISTING WASH FACILITIES, SY 2019-2020 (As of June 30, 2019) Revised SCH HEALTH
36 36 Table 36. ORAL HEALTH, PREVIOUS SY 2018-2019 Revised SCH HEALTH
37 36 Table 37. MEDICAL AND NURSING SERVICES, PREVIOUS SY 2018-2019 Revised SCH HEALTH
13 37 Box 13. MENTAL HEALTH, PREVIOUS SY 2018-2019 Revised SCH HEALTH
14 38 Box 14. TOBACCO CONTROL, SY 2019-2020 Revised SCH HEALTH
15 38 Box 15. NATIONAL PREVENTIVE DRUG EDUCATION, SY 2019-2020 Revised SCH HEALTH
16 39 Box 16. FEEDING PROGRAM, SY 2019-2020 (As of August 31, 2019) Revised SCH HEALTH
17 39 Box 17. FOOD HANDLING, SY 2019-2020 (As of August 31, 2019) Revised SCH HEALTH
18 40 Box 18. SOLID WASTE MANAGEMENT, SY 2019-2020 (As of June 30, 2019) Revised SCH HEALTH
19 40 Box 19. OPERATION AND MAINTENANCE OF SANITATION FACILITIES, SY 2019-2020 (As of June 30, 2019) Revised SCH HEALTH
20 40 Box 20. MENSTRUAL HYGIENE, SY 2019-2020 (As of June 30, 2019) Revised SCH HEALTH
21 41 Box 21 . SCHOOL SPORTS PROGRAM, SY 2019-2020 (As of June 30, 2019) AVAILABLE SPORTS EVENTS, CLUBS, AND FACILITIES Revised SPORTS
38 42 Table 38 . SCHOOL SPORTS PROGRAM, SY 2019-2020 (As of June 30, 2019) SPORTS PERSONNEL (DepEd Funded) DATA Revised SPORTS
39 43 Table 39. DISASTERS/CALAMITIES, For the months of June 2018 to May 2019 Revised DRRM
44 (Cont. of Table 39) Revised DRRM
40 45 Table 40. DISASTERS/CALAMITIES (Human-Induced Hazards - Armed Conflict and Grave Child Rights Violations), For the months of June 2018 to May 2019 Revised DRRM
41 46 Table 41. RESULT OF DISASTER INCIDENCES, For the months of June 2018 to May 2019 Revised DRRM
22 47 Box 22. ENABLING ENVIRONMENT, For the months of June 2018 to May 2019 Revised DRRM
23 48 Box 23. SAFE LEARNING FACILITIES, For the months of June 2018 to May 2019 Revised DRRM
24 49 Box 24. DISASTER RISK MANAGEMENT, For the months of June 2018 to May 2019 Revised DRRM
50 (Cont. of Box 24) Revised DRRM
25 51 Box 25. DISASTER RISK REDUCTION IN EDUCATION, For the months of June 2018 to May 2019 Revised DRRM
42 52 Table 42. DISASTER RISK REDUCTION IN EDUCATION (DRRM, CCA, and Peacebuilding Trainings), For the months of June 2018 to May 2019 Revised DRRM
26 53 Box 26. DISASTER RISK REDUCTION IN EDUCATION Revised DRRM
27 54 Box 27. ARMED-CONFLICT RELATED INITIATIVES, For the months of June 2018 to May 2019 Revised DRRM

434240354.xlsx List of Tables & Boxes

 School ID

Republic of the Philippines

DEPARTMENT OF EDUCATION
PLANNING SERVICE
Education Management Information System Division

GOVERNMENT ELEMENTARY SCHOOL PROFILE

INSTRUCTIONS

This form shall be accomplished by the head of all government elementary schools. In the case of schools with annexes, extensions, etc., a separate school profile shall be accomplished by every
annex, extension, etc.
The head of the school shall sign the forms certifying to the correctness of the data, and shall be responsible and accountable for any inaccuracy or false data/information reported. He/She shall
submit the accomplished forms to the respective Schools Division Office (SDO).
Important: Read the definitions/instructions found at the bottom of each table before filling up the form. No item should be left blank. Instead, "zero ( 0 )" or "not applicable (n/a) " shall be
written. Shaded boxes shall not be filled.

SCHOOL INFORMATION
SY 2019-2020

Name of School : Region :

(Official Name) Division :
School District :
(Previous Name, if any) Legislative District :
Address : Telephone Number :
No. Street/Sitio/Purok Barangay Mobile Number :
Fax Number :
Municipality/City Province Zip Code Website (if any) :
E-Mail Address :
Date Established :

Please check (a ) if the school is: Please check (a ) if the school has the following Curricular Offering Classification (COC):
a Central School Kindergarten
a SPED Center Grades 1 to 6
with SPED Classes
an Annex/Extension School (please indicate Mother School ID: ______________ )

Certified True and Correct by : Validated by Planning Officer III (PRS-SGOD): Noted by the Schools Division Office :
School Head : Head of the Office :
(Signature Over Printed Name) (Signature Over Printed Name)

Position Title : ____________________ Date : ___________ Signature Over Printed Name / Date Position Title : Date :

434240354.xlsx SchInfo Page 1 of 54

 Table 34. HEALTH AND NUTRITION, SY 2019-2020

A. Number of learners who were vaccinated by the Department of Health in the school this SY 2019-2020 from June 3, 2019 to August 31, 2019
Grade 1 Grade 4
Types of Vaccines
Male Female Total Female
Measles Containing Vaccine
Tetanus Diphtheria
Human Papiloma Virus

B. Number of learners who underwent vision screening according to results from June 3, 2019 to August 31, 2019
TOTAL
Kindergarten Grade 1 Grade 2 Grade 3 (Kindergarten to Grade
Vision Screening Results 3)
Male Female Male Female Male Female Male Female Male Female
Passed
Failed
TOTAL

C. Number of learners by nutritional status as assessed from June 3, 2019 to August 31, 2019
Learners with TOTAL
Special Educational
Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Needs (Kindergarten to
Nutritional Status Non-Graded LSENs)
(Non-Graded)
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
Weight
Normal
Obese
Overweight
Severely Wasted
Wasted
TOTAL
Height
Severely Stunted
Stunted
Normal
Tall
TOTAL
Notes:
Learners Nutritional Status in Weight:
1. Normal - refers to a learner with normal weight for his/her age whose BMI-for-age fall between -2 to +2 z-score line or standard deviation (SD).
2. Obese - refers to a learner who is severely overweight for his/her height and whose BMI-for-age fall beyond +3 z-score line or standard deviation (SD).
3. Overweight - refers to a learner weighing too much for his/her height and whose BMI-for-age fall between +2 to +3 z-score line or standard deviation (SD).
4. Severely wasted - refers to a very thin learner whose BMI-for-age is below -3 z-score line or standard deviation (SD).
5. Wasted - refers to a thin learner whose BMI-for-age fall between -2 to -3 z-score line or standard deviation (SD).
Learners Nutritional Status in Height:
1. Severely Stunted - refers to a learner who is very short for his/her age and whose height-for-age (HFA) fall below -3 z-score line or standard deviation (SD).
2. Stunted - refers to a learner who is short for his/her age and whose height-for-age (HFA) fall between -2 to -3 z-score line or standard deviation (SD).
3. Normal - refers to a learner with normal height for his/her age and whose height-for-age (HFA) fall between -2 to +2 z-score line or standard deviation (SD).
4. Tall - refers to a learner who is tall for his/her age and whose height-for-age (HFA) fall beyond +2 z-score line or standard deviation (SD).

D. Number of learners who were dewormed from June 3, 2019 to August 31, 2019
TOTAL
Learners with
Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Disabilities (Kindergarten to
Non-Graded LWDs)
Number of Learners Dewormed (Non-Graded)
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
5 7 5 6 10 7 10 4 3 3 5 7 9 9 47 43

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/Nurse: Validated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date

434240354.xlsx Table34 Page 33 of 54

 Box 11. SCHOOL CLINIC, SY 2019-2020
(Please check/provide appropriate answers)

1. Does the school have a designated school clinic?  Yes  No

2. How many weighing scales does the school have?

Number of Units Available

Type of Weighing Scale
in the School
Bathroom
Beam balance

Others, please specify________________________

3. Which of the following tools does the school use for taking height?
 Tape Measure  Microtoise  Others, please specify ____________________
 Steel tape  Stadiometer
4. How many first aid kits does the school have? ____________________

5. How many medical thermometers does the school have? ____________________

6. How many blood pressure apparatus does the school have? ____________________

7. How many school personnel has a training on basic life support and/or first aid? ____________________

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/Nurse: Validated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date

434240354.xlsx Box11 Page 34 of 54

 Box 12. AVAILABILITY OF WATER SUPPLY, SY 2019-2020 (As of June 30, 2019)
(Check as appropriate)
1. Is there a water source inside the school ground?  Yes  No
If Yes,
1.1. Main Water Supply Source:
 Piped water from local service provider  Rainwater Catchments
 Water Well  Others, please specify ____________________
 Natural source
1.2. Average Cost of Monthly Bills/Maintenance: (Please indicate the amount in PhP)_________________
1.3. Who pays for the Cost of Monthly Bills/Maintenance?
 School MOOE  School Canteen Fund
 LGU  Private Individual/Sector
 PTA  Others, please specify ____________________
1.4. Is the water source inside the school ground being used for drinking?  Yes  No
1.5. Has the water source inside the school been tested to determine safety of the water?  Yes  No
1.5.a. If Yes, did the test results show that the water source inside the school is safe to drink?  Yes  No
1.5.b. How frequent is the water source tested for safety?
 Monthly  Annually
 Quarterly  Others, please specify ____________________
1.5.c. When was the last time the water source was tested? ____________________
1.6. Are there times in the year when water is not available for an extended period of time?  Yes  No

2. Does the school have mechanism to ensure that the learners have safe drinking water?  Yes  No
2.1. If Yes, what mechanism is used?
 Teachers ask the learners to bring their own drinking water to school
 Safe water in refillable containers are provided in designated areas within the school
 Water from an accessible water source is treated (i.e., boiled, etc.)
 Others, please specify ____________________
1. Local piped water - water source coming from local water service providers.
2. Water well - an excavation structure in the ground by digging, driving, boring or drilling to access water in underground aquifiers.
3. Rainwater catchment - water sourced from rainwater and collected thru a rainwater collector.
4. Natural source - water sourced from a spring or stream that is either located inside the school grounds or located outside school grounds but water is supplied via pipes.

Table 35. NUMBER OF EXISTING WASH FACILITIES, SY 2019-2020 (As of June 30, 2019)
Functional Total Number Number
Usage Non-Functional of of
with soap without soap Facilities Water Outlets

Facilities for group handwashing

Facilities for individual handwashing
1. Group handwashing facility - a facility to be used in supervised handwashing and toothbrushing activtity that can accommodate at least 10 learners.
2. Individual handwashing facility - a facility in the classroom, drinking points, near toilets, near the canteen, etc. that learners can be used for handwashing at critical times.
3. Functional facilities for handwashing - the hand washing facility is accessible, with daily water supply, learner-appropriate height and with appropriate drainage.
4. Non-functional facilities for handwashing - the hand washing facility is broken, clogged or damaged in such a way that it cannot be used.
5. Water Outlet - any opening where water comes out for handwashing (e.g., Faucets, Punch Pipes, etc.).

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/Nurse: Validated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date

434240354.xlsx Box12-Table35 Page 35 of 54

 Table 36. ORAL HEALTH, PREVIOUS SY 2018-2019
TOTAL
Details Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
(Kindergarten to Grade 6)
Number of Learners Examined
Decayed, Missing, and Filled Teeth (DMFT) - Permanent Teeth
No. of Learners with DMFT
No. of DMFT
Decayed, Missing, and Filled Teeth (DMFT) - Temporary Teeth
No. of Learners with DMFT
No. of DMFT
Number of Learners Found to Have Gum Disease
Number of Learners with Other Significant Dental Anomalies
Number of Learners who Underwent Flouridization

Notes:
1. Decayed, Missing, and Filled Teeth (DMFT) Index - refers to the common method use in oral epidemology for assessing dental carries prevalence as well as dental treatment needs among
2. populations.
Gum Disease - refers to an inflammation of the gum line that can progress to affect the bone that surrounds and supports the teeth.
3. Dental Anomalies - refers to the craniofacial abnormalities of form, function or position of the teeth, bones, and tissues of the jaw and mouth.
4. Fluoridization - refers to the topical application of fluoride compounds onto the tooth surface to reduce the incidence of dental caries.
 

Table 37. MEDICAL AND NURSING SERVICES, PREVIOUS SY 2018-2019

TOTAL
Details Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
(Kindergarten to Grade 6)
Number of Learners Examined 20 24 18 8 13 20 13 116

Number of Learners with Findings 18 8 16 8 13 20 13 96

Number of Learners Given Interventions by Clinic Teachers and
0 0 0 0 0 0 0 0
DepEd Health Personnel
Number of Learners Referred to City/Rural Health Units or Other
0 0 0 0 1 (ICTERIC SCLERAE) 1 (DEAF-MUTE) 0 2
Private Health Professionals

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/NurseValidated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date
434240354.xlsx Tbls36-37 Page 36 of 54
 Box 13. MENTAL HEALTH, PREVIOUS SY 2018-2019
(Please provide appropriate answers)

1. Number of learners who sought guidance counseling or life coaching from the school’s guidance counselor or guidance advocate:

Grade Level Number of Learners

Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
TOTAL

2. Number of cases of violence against children committed in schools that were recorded by the school:
Types of Violence Cases Committed
Against Children Against Male Learners Against Female Learners Total
Physical violence
Sexual violence
Psychological violence
Other acts of violence
TOTAL

3. Number of cases of bullying or peer abuse that were recorded by the school:

Grade Level Number of Cases

Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
TOTAL

4. Number of cases of suicide and attempted suicide among learners and school personnel that were recorded by the school:
Number of Cases
Cases
Among Learners Among School Personnel
Suicide
Attempted suicide

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/NursValidated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date
434240354.xlsx Box13 Page 37 of 54
 Box 14. TOBACCO CONTROL, SY 2019-2020
(Please check/provide appropriate answers)

1. Does the school display the following IEC materials:

1.a. "No Smoking" Signages (EO 26, s.2017, DO 48, s.2016)  Yes  No
1.b. Poster at the school gate about prohibition of selling of cigarettes within 100 meters from the perimeter of the school
(EO 26, s.2017)
 Yes  No
2. Does the school have an active Child Protection Committee (CPC)?  Yes  No
2.a. How frequent does the CPC meet?  Monthly  Quarterly  Annually  Others, please specify ____________________
2.b. Has the school's CPC met to discuss tobacco control?  Yes  No
2.c. When did the CPC last meet to discuss tobacco control? (mm/dd/yyyy) ________________________
2.d. Does the school's CPC monitor stores within the 100-meter perimeter of the school for reporting to authorities stores
that sell cigarettes?  Yes  No
2.e. How frequent does the CPC monitor the stores within the 100-meter perimeter of the school?
 Monthly  Quarterly  Annually  Others, please specify ____________________
2.f. When did the CPC last monitor stores within the school's 100-meter perimeter to report violation
to authorities? (mm/dd/yyyy) ________________________

3. Measures Against Tobacco Industry Interference:

3.a. How many partnerships did the school have from May 2017 to August 2018? ________________________
3.b. How many of these partnerships have the proper partnership instrument needed (e.g., service contract, memorandum
of agreement (MOA), deed of donation (DOD)/deed of acceptance, memorandum of understanding, etc.)? ________________________
3.c. How many of the partnerships with memoranda of agreement/deeds of donation include a provision in the
MOA/DOD that the partner/donor is not connected to the tobacco industry, does not received funding from tobacco
companies, or does not sell cigarettes?
________________________

Box 15. NATIONAL PREVENTIVE DRUG EDUCATION, SY 2019-2020

(Please check/provide appropriate answers)

1. Does the school implement a preventive drug education program?  Yes  No

2. Which of the following components are part of the school's preventive drug education program?
 Curriculum integration  Partnership with the Barangay Anti-Drug Abuse Council
 Extra-curricular activities  Others, please specify __________
3. Does the school have a National Drug Education Program (NDEP) Coordinator?  Yes  No
4. How many classrooms have NDEP Corners? ____________________________

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/Nurse: Validated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date
434240354.xlsx Boxes14-15 Page 38 of 54
 Box 16. FEEDING PROGRAM, SY 2019-2020 (As of August 31, 2019)
(Check as appropriate)

1. Does the school have a feeding program?  Yes  No

If Yes, what is the funding source of school feeding program?
 School MOOE  LGU Fund  Barangay Fund  School-Based Feeding Program (SBFP)
 School Canteen Fund  PTA Fund  Private Individual/Sector Fund  Others, please specify ____________________
2. Availability of agriculture and fishery resources in the school :
 Gulayan sa Paaralan, If check, which of the following types of vegetables are present in the school garden?
 Legumes  Leafy vegetables  Fruit-bearing  Rootcrops
 Fish Pond
 Agricultural Crops
 Livestock
 Others, please specify ____________________
 None
3. Does agricultural and fishery in the school used for feeding program?  Yes  No
If Yes, what is the funding source?
 School MOOE  LGU Fund  Barangay Fund  Others, please specify ____________________
 School Canteen Fund  PTA Fund  Private Individual/Sector Fund

Box 17. FOOD HANDLING, SY 2019-2020 (As of August 31, 2019)

(Please check/provide appropriate answers)

1. Does the school have a canteen?  Yes  No

If Yes,
1.a. Managed by: 1.b. Sanitary Permit 1.c. Validity Date 1.d. Do canteen personnel/food
handlers have health certificates?

 School ____________________ ____________________  Yes  No

 Teacher-Coop ____________________ ____________________  Yes  No

 Others, please specify

____________________ ____________________ ____________________  Yes  No

Sanitary Permit - is the official document issued by proper authorities to an establishment that has been determined to have met the minimum requirements for the
sanitary operation.

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/Nurse: Validated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date
434240354.xlsx Boxes16-17 Page 39 of 54
 Box 18. SOLID WASTE MANAGEMENT, SY 2019-2020 (As of June 30, 2019)

1. Is your school compliant to the Ecological Solid Waste Management Act (RA 9003)?  Yes  No

2. How is the school implementing Solid Waste Management? (Check as appropriate)

 Composting  Posting of signage  Use of paper plates/cups instead of plastic
 Designation of trash collection point  Recycling Projects  Use of recycled materials are teaching tool
 Poster making and/or slogan making contest  School representative at the Barangay Solid  Use of reusable food containerts
Waste Management Committee  Waste segregation

3. Who are the school stakeholders actively engaged on the implementation of solid waste management? (Check as appropriate)
 Barangay  Local business partners  Parents
 Community leaders  Municipal/City government

Box 19. OPERATION AND MAINTENANCE OF SANITATION FACILITIES, SY 2019-2020 (As of June 30, 2019)

1. How often are the sanitation facilites cleaned? (Check only one)
 Daily  Once a week
 At least twice a week  Less than once a week
1.1. Average Cost of Monthly Bills/Maintenance: (Please indicate the amount) ______________
1.2. Who Pays for the Cost of Monthly Bills/Maintenance? (Check as appropriate)
 School MOOE  School Canteen Fund
 LGU  Private Individual/Sector
 PTA  Others, please specify ____________________

Box 20. MENSTRUAL HYGIENE, SY 2019-2020 (As of June 30, 2019)

(Check as appropriate)

Does the school have a provision for availability of sanitary pads?  Yes  No
If Yes, where can the learners avail the sanitary pads?
 School Canteen  Guidance Office
 School Clinic  Others, please specify ____________________

Certified True and Correct by : Validated by Division School Health Coordinator/Medical Officer/Nurse: Validated by Planning Officer III (PRS-SGOD):
School Head : DONNA MICHELLE R. CRUZ
(Signature Over Printed Name) / Date (Signature Over Printed Name) / Date
Position Title : Position Title : (Signature Over Printed Name) / Date
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