SBFP Form 1 (2021)

Department of Education
Region XIII
Master List Beneficiaries for School-Based Feeding Program (SBFP) (SY: 2021-2022)
COMMERCIAL MILK
Division/Province: AGUSAN DEL SUR Name of Principal : LEO D. VALLE
City/ Municipality/Barangay : PROSPERIDAD/ SAN ROQUE Name of Feeding Focal Person : RONNALIE J. REPONTE
Name of School / School District : SAN ROQUE ELEMENTARY SCHOOL / PROSPERIDAD V
School ID Number: 131787

Parent's Beneficiary
Nutritional
Date of Weighing / Age in BMI for 6 Dewormed? consent Participation of SBFP in
No. Name Sex Grade/ Section Date of Birth Measuring Years / Weight Height y.o. and Status (NS) (yes for milk? in 4Ps Previous
(MM/DD/YYYY) (Kg) (cm)
(MM/DD/YYYY) Months above or no) (yes or no) Years (yes or
(yes or no)
BMI-A HFA no)

1 Baguio, Alden N. M Kinder-A 9/27/2015 YES YES YES NO

2 Betcher, Antonio B. M Kinder-A 2/24/2016 YES YES YES NO
3 Genita, Jayrus M Kinder-A 2/2/2016 YES YES NO NO
4 Jaralve, Ariel Jake L. M Kinder-A 2/2/2016 YES YES YES NO
5 Lastimoso, Riens Xyrics B. M Kinder-A 4/62016 YES YES NO NO
6 Maloloy-on, Jecson C. M Kinder-A 6/10/2016 YES YES NO NO
7 Perez, Regie G. M Kinder-A 12/6/2015 YES YES YES NO
8 Tomas, Jaymark A. M Kinder-A 10/2/2016 YES YES NO NO
9 Caral, Janella Clear B. F Kinder-A 6/29/2016 YES YES YES NO
10 Heolin, Marialyn B. F Kinder-A 5/7/2016 YES YES YES NO
11 Patriarca, Ayesha Pearl S. F Kinder-A 2/5/2016 YES YES NO NO
12 Faustor, Denver Jade M Grade 1 - Ampalaya 9/28/2014 9/13/2021 6 15 119 10.59 SW YES YES YES YES
13 Glodobe, Elijah I. M Grade 1 - Ampalaya 12/2/2014 9/13/2021 6 16 114 12.31 W YES YES NO YES
14 Maningo, Kian John F. M Grade 1 - Ampalaya 8/2/2015 9/13/2021 6 18 119 12.71 W YES YES YES YES
 Parent's Beneficiary
No. Grade/ Section Date of Weighing / Age in BMI for 6 Nutritional Dewormed? consent Participation of SBFP in
Date of Birth Weight Height Status (NS) (yes for milk? in 4Ps
Name Sex (MM/DD/YYYY)
Measuring Years /
(Kg) (cm)
y.o. and Previous
(MM/DD/YYYY) Months above or no) (yes or no) Years (yes or
(yes or
no)
BMI-A HFA no)
15 Faustor, Leah Joy O. F Grade 1 - Ampalaya 5/11/2014 9/13/2021 6 16.5 116 12.26 W YES YES YES YES
16 Libradilla, Althea F. Grade 1 - Ampalaya 10/27/2015 9/13/2021 6 15 115 11.34 SW YES YES NO YES
17 Baylosis, Jermiel P. M Grade 2 -Faith 10/13/2012 9/14/2021 8 19.3 123 12.76 W YES YES NO NO
18 Salazar, Roy Jr. M. M Grade 2 -Faith 11/17/2012 9/14/2021 8 18.2 123 12.03 SW YES YES YES NO
19 Glodove, Chona G. F Grade 2 -Faith 10/15/2013 9/14/2021 7 17.2 122 11.56 SW YES YES NO NO
20 Lobingco, Jhon Kris G. M Grade 3- Mango 4/30/2013 9/15/2021 8 15.2 114 11.7 SW YES YES YES NO
21 Menorias, AJ Bryan L. M Grade 3- Mango 12/19/2012 9/15/2021 8 17.5 119 12.36 W YES YES NO NO
22 Pongase, Anthony M Grade 3- Mango 4/24/2013 9/15/2021 7 17.3 117 12.64 W YES YES NO NO
23 Gonzales, Chayrine D. F Grade 3- Mango 6/28/2013 9/15/2021 7 16.8 116 12.49 W YES YES NO YES
24 Faustor, John Carlo King M Grade 4- Diamond 2/25/2014 9/16/2021 7 16.4 115 12.4 W YES YES NO NO
25 Zalazar, Briant Rhai M. M Grade 4- Diamond 11/18/2014 9/16/2021 6 15.6 112 12 SW YES YES NO NO
26 Tuba, Mark B. M Grade 5- Agapitong 5/12,2011 9/16/2021 8 18.4 126 11.59 SW YES YES YES YES
27 Nakila, Karl Ivan P. M Grade 6- Rizal 7/20/2010 9/17/2021 10 23.4 134 13.03 W YES YES NO NO
28 Maninggo, Shane G. F Grade 6- Rizal 10/25/2010 9/17/2021 10 21.4 131 12.47 SW YES YES NO NO

Prepared by: Approved by:

LEO D. VALLE
RONNALIE J. REPONTE School Head
Feeding Focal Person

Note: This form shall be prepared by the school before the start of feeding to be compiled by the SDO.
Keep columns 6-12 blank if nutritional assesment is still suspended.
Patriarca, Ayesha Pearl S.
2/5/2016
SBFP Form 1 (2021)
Department of Education
Region XIII
Master List Beneficiaries for School-Based Feeding Program (SBFP) (SY: 2021-2022)
NUTRITIOUS FOOD PRODUCTS
Division/Province: AGUSAN DEL SUR Name of Principal : LEO D. VALLE
City/ Municipality/Barangay : PROSPERIDAD/ SAN ROQUE Name of Feeding Focal Person : RONNALIE J. REPONTE
Name of School / School District : SAN ROQUE ELEMENTARY SCHOOL / PROSPERIDAD V
School ID Number: 131787

Parent's Beneficiary
Nutritional
Date of Weighing / Age in BMI for 6 Dewormed? consent Participation of SBFP in
No. Name Sex Grade/ Section Date of Birth Measuring Years / Weight Height y.o. and Status (NS) (yes for milk? in 4Ps Previous
(MM/DD/YYYY) (Kg) (cm)
(MM/DD/YYYY) Months above or no) (yes or no) Years (yes or
(yes or no)
BMI-A HFA no)

1 Baguio, Alden N. M Kinder-A 9/27/2015 YES YES YES NO

2 Betcher, Antonio B. M Kinder-A 2/24/2016 YES YES YES NO
3 Genita, Jayrus M Kinder-A 2/2/2016 YES YES NO NO
4 Jaralve, Ariel Jake L. M Kinder-A 2/2/2016 YES YES YES NO
5 Lastimoso, Riens Xyrics B. M Kinder-A 4/62016 YES YES NO NO
6 Maloloy-on, Jecson C. M Kinder-A 6/10/2016 YES YES NO NO
7 Perez, Regie G. M Kinder-A 12/6/2015 YES YES YES NO
8 Tomas, Jaymark A. M Kinder-A 10/2/2016 YES YES NO NO
9 Caral, Janella Clear B. F Kinder-A 6/29/2016 YES YES YES NO
10 Heolin, Marialyn B. F Kinder-A 5/7/2016 YES YES YES NO
11 Patriarca, Ayesha Pearl S. F Kinder-A 2/5/2016 YES YES NO NO
12 Faustor, Denver Jade M Grade 1 - Ampalaya 9/28/2014 9/13/2021 6 15 119 10.59 SW YES YES YES YES
13 Glodobe, Elijah I. M Grade 1 - Ampalaya 12/2/2014 9/13/2021 6 16 114 12.31 W YES YES NO YES
14 Maningo, Kian John F. M Grade 1 - Ampalaya 8/2/2015 9/13/2021 6 18 119 12.71 W YES YES YES YES
 Parent's Beneficiary
No. Grade/ Section Date of Weighing / Age in BMI for 6 Nutritional Dewormed? consent Participation of SBFP in
Date of Birth Weight Height Status (NS) (yes for milk? in 4Ps
Name Sex (MM/DD/YYYY)
Measuring Years /
(Kg) (cm)
y.o. and Previous
(MM/DD/YYYY) Months above or no) (yes or no) Years (yes or
(yes or
no)
BMI-A HFA no)
15 Faustor, Leah Joy O. F Grade 1 - Ampalaya 5/11/2014 9/13/2021 6 16.5 116 12.26 W YES YES YES YES
16 Libradilla, Althea F. Grade 1 - Ampalaya 10/27/2015 9/13/2021 6 15 115 11.34 SW YES YES NO YES
17 Baylosis, Jermiel P. M Grade 2 -Faith 10/13/2012 9/14/2021 8 19.3 123 12.76 W YES YES NO NO
18 Salazar, Roy Jr. M. M Grade 2 -Faith 11/17/2012 9/14/2021 8 18.2 123 12.03 SW YES YES YES NO
19 Glodove, Chona G. F Grade 2 -Faith 10/15/2013 9/14/2021 7 17.2 122 11.56 SW YES YES NO NO
20 Lobingco, Jhon Kris G. M Grade 3- Mango 4/30/2013 9/15/2021 8 15.2 114 11.7 SW YES YES YES NO
21 Menorias, AJ Bryan L. M Grade 3- Mango 12/19/2012 9/15/2021 8 17.5 119 12.36 W YES YES NO NO
22 Pongase, Anthony M Grade 3- Mango 4/24/2013 9/15/2021 7 17.3 117 12.64 W YES YES NO NO
23 Gonzales, Chayrine D. F Grade 3- Mango 6/28/2013 9/15/2021 7 16.8 116 12.49 W YES YES NO YES
24 Faustor, John Carlo King M Grade 4- Diamond 2/25/2014 9/16/2021 7 16.4 115 12.4 W YES YES NO NO
25 Zalazar, Briant Rhai M. M Grade 4- Diamond 11/18/2014 9/16/2021 6 15.6 112 12 SW YES YES NO NO
26 Tuba, Mark B. M Grade 5- Agapitong 5/12,2011 9/16/2021 8 18.4 126 11.59 SW YES YES YES YES
27 Nakila, Karl Ivan P. M Grade 6- Rizal 7/20/2010 9/17/2021 10 23.4 134 13.03 W YES YES NO NO
28 Maninggo, Shane G. F Grade 6- Rizal 10/25/2010 9/17/2021 10 21.4 131 12.47 SW YES YES NO NO

Prepared by: Approved by:

LEO D. VALLE
RONNALIE J. REPONTE School Head
Feeding Focal Person

Note: This form shall be prepared by the school before the start of feeding to be compiled by the SDO.
Keep columns 6-12 blank if nutritional assesment is still suspended.
Patriarca, Ayesha Pearl S.
2/5/2016
SBFP Form 2 (2021)
Department of Education
Region XIII
SCHOOL-BASED FEEDING PROGRAM (SBFP) SUMMARY OF BENEFICIARIES & START OF FEEDING (SY: 2021-2022)
COMMERCIAL MILK

Division/Province: DIVISION OF AGUSAN DEL SUR

City/ Municipality/Barangay : PROSPERIDAD / SAN ROQUE
Name of School / School District : SAN ROQUE ELEMENTARY SCHOOL / PROSPERIDAD V
School ID Number: 131787
Date of Start of Feeding:
Last Mile School: Y N

No. of Secondary Targets No. of Pupils who

Nutritional Status at Start/End of Feeding are beneficiaries
Number of SW W N OW+O SS S N T No. of Pupils- No. of No. of No. of No. of 4 in previous years
Undernourished School at-risk-of- Stunted/ Indigent Indigenous Learners No. of 4 Ps (Repeaters) Date Feeding
Children by Grade Level dropping-out Severely Learners Peoples Dewormed Beneficiaries Started/Ended
(PARDOs) Stunted (IPs)

1. Kinder 0 0 11 0 11 6 0

2. Grade I 2 3 0 0 5 3 5

3. Grade II 2 1 0 0 3 1 0

4. Grade III 1 3 0 0 4 1 1

5. Grade IV 1 1 0 0 2 0 0

6. Grade V 1 0 0 0 1 1 1

7. Grade VI 1 1 0 0 2 0 0
Total 8 9 11 0 28 12 7

Prepared by: Approved by:

RONNALIE J. REPONTE LEO D. VALLE

SBFP DepEd Focal School Head

Note: This form shall be prepared by the school before the start of feeding and after feeding, to be compiled by the SDO, and for final compilation by the RO, for submission to DepEd
BLSS-SHD
SBFP Form 2 (2021)
Department of Education
Region XIII
SCHOOL-BASED FEEDING PROGRAM (SBFP) SUMMARY OF BENEFICIARIES & START OF FEEDING (SY: 2021-2022)
NUTRITIOUS FOOD PRODUCTS

Division/Province: DIVISION OF AGUSAN DEL SUR

City/ Municipality/Barangay : PROSPERIDAD / SAN ROQUE
Name of School / School District : SAN ROQUE ELEMENTARY SCHOOL / PROSPERIDAD V
School ID Number: 131787
Date of Start of Feeding:
Last Mile School: Y N
No. of Secondary Targets No. of Pupils
Nutritional Status at Start/End of Feeding who are
Number of SW W N OW+O SS S N T No. of Pupils- No. of No. of No. of No. of 4 beneficiaries in
Undernourished School at-risk-of- Stunted/ Indigent Indigenous Learners No. of 4 Ps previous years Date Feeding
Children by Grade Level dropping-out Severely Learners Peoples Dewormed Beneficiaries (Repeaters) Started/Ended
(PARDOs) Stunted (IPs)

1. Kinder 0 0 11 0 11 6 0

2. Grade I 2 3 0 0 5 3 5

3. Grade II 2 1 0 0 3 1 0

4. Grade III 1 3 0 0 4 1 1

5. Grade IV 1 1 0 0 2 0 0

6. Grade V 1 0 0 0 1 1 1

7. Grade VI 1 1 0 0 2 0 0
Total 8 9 11 0 28 12 7

Prepared by: Approved by:

RONNALIE J. REPONTE LEO D. VALLE

SBFP DepEd Focal School Head

Note: This form shall be prepared by the school before the start of feeding and after feeding, to be compiled by the SDO, and for final compilation by the RO, for submission to DepEd
BLSS-SHD
 SBFP Form 3 (2021)
SCHOOL-BASED FEEDING PROGRAM
RECORD OF DAILY FEEDING

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________
School ID Number: _________________________
NAME OF PUPIL ACTUAL FEEDING

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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
TOTAL:
Prepared by:
 ____________________________
B. Deworming D. Actual Feeding
Feeding Teacher / School Nurse
( x ) - not dewormed (H ) - Present, served with Hot meals
Approved by: ( √ ) - dewormed (M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
School Head (H2/M2/(H/M2)) - Present, served twice

Note: This form shall be prepared by the school to be consolidated using the Revised OKD Form A.
16 17 18 19 20
 SBFP Form 3 (2021)

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________
School ID Number: _________________________

ACTUAL FEEDING

NAME OF PUPIL

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
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
TOTAL:

page 2
 D. Actual Feeding

(H ) - Present, served with Hot meals

(M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
(H2/M2/(H/M2)) - Present, served twice

page 2
53 54 55 56 57 58 59 60

page 2
 SBFP Form 3 (2021)

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________
School ID Number: _________________________

ACTUAL FEEDING

NAME OF PUPIL

61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92
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
TOTAL:

page 3
 D. Actual Feeding

(H ) - Present, served with Hot meals

(M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
(H2/M2/(H/M2)) - Present, served twice

page 3
93 94 95 96 97 98 99 100

page 3
 SBFP Form 3 (2021)

SCHOOL-BASED FEEDING PROGRAM

FOR THE MONTH OF ______________________ , SY _____________

Region ____________________________
Division ___________________________ School: _____________________________________
District ___________________________ Grade: __________ Section _____________________
School ID Number: _________________________

ACTUAL FEEDING
ATTENDANCE
NAME OF PUPIL No. of
Days
Present
101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 (A)
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
TOTAL: AVERAGE:

page 4
 D. Actual Feeding

(H ) - Present, served with Hot meals

(M ) - Present, served with Milk
(H/M ) - Present, served with Hot meals & Milk
( A ) - Absent, not served
(H2/M2/(H/M2)) - Present, served twice

page 4
ATTENDANCE
No. of
Feeding Percentage
Days
(B) (A/B)*100

AVERAGE:

page 4
SBFP Form 5 (2020)

DEPARTMENT OF EDUCATION
Region XIII

REGION/DIVISION/DISTRICT: CARAGA / AGUSAN DEL SUR / PROSPERIDAD V

NAME OF SCHOOL: SAN ROQUE ELEMENTARY SCHOOL
SCHOOL ID NO.: 131787

SCHOOL-BASED FEEDING PROGRAM - MILK COMPONENT

LIST OF AUTHORIZED CONSIGNEES (SY: 2021-2022)

NAME & DESIGNATION

TEL. NO. MOBILE NO. EMAIL ADD SPECIMEN SIGNATURE

ROLANDO L. RESTAURO 09197436270

District-Incharge

LORENA R. DAPO 09159617736

ADAS

MERLY D. BIOJON
District Property Custodian

SCHOOL INSPECTION TEAM (SY: 2021-2022)

NAME & DESIGNATION TEL. NO. MOBILE NO. EMAIL ADD SPECIMEN SIGNATURE

1. LEO D. VALLE 09383177831 [email protected]

2. RONNALIE J. REPONTE 09489383150 [email protected]

3. DEMETRITO L. GLODOBE JR. 09468016552 [email protected]

Note: Only authorized consignees are allowed to receive the goods.

SBFP Form 5 (2020)

DEPARTMENT OF EDUCATION
Region XIII

REGION/DIVISION/DISTRICT: CARAGA / AGUSAN DEL SUR / PROSPERIDAD V

NAME OF SCHOOL: SAN ROQUE ELEMENTARY SCHOOL
SCHOOL ID NO.: 131787

SCHOOL-BASED FEEDING PROGRAM - NUTRITIOUS FOOD PRODUCTS

LIST OF AUTHORIZED CONSIGNEES (SY: 2021-2022)

NAME & DESIGNATION

TEL. NO. MOBILE NO. EMAIL ADD SPECIMEN SIGNATURE

ROLANDO L. RESTAURO 09197436270

District-Incharge

LORENA R. DAPO 09159617736

ADAS

MERLY D. BIOJON
District Property Custodian

SCHOOL INSPECTION TEAM (SY: 2021-2022)

NAME & DESIGNATION TEL. NO. MOBILE NO. EMAIL ADD SPECIMEN SIGNATURE

1. LEO D. VALLE 09383177831 [email protected]

2. RONNALIE J. REPONTE 09489383150 [email protected]

3. DEMETRITO L. GLODOBE JR. 09468016552 [email protected]

Note: Only authorized consignees are allowed to receive the goods.

SBFP Form 5 (2021)

DEPARTMENT OF EDUCATION
Region ___

REGION/DIVISION/DISTRICT: ______________________________________________________________________________
NAME OF SCHOOL: ______________________________________________________________________________
SCHOOL ID NO.: ______________________________________________________________________________

SCHOOL-BASED FEEDING PROGRAM - MILK COMPONENT

LIST OF BENEFICIARIES (SY________)

Classification of Students in terms of Milk Tolerance
(Please check one)
Without milk With milk Not allowed by
intolerance and will intolerance but parents to
Name Grade & Section participate in milk willing to participate in milk
feeding participate in milk feeding
feeding
SBFP Form 5 (2021)

Prepared by: APPROVED BY:

School Feeding Coordinator School Head

SBFP Form 6 (2021)

DEPARTMENT OF EDUCATION
Region XIII

REGION/DIVISION/DISTRICT: CARAGA / DIVISION OF AGUSAN DEL SUR / PROSPERIDAD V

NAME OF SCHOOL: SAN ROQUE ELEMENTARY SCHOOL
SCHOOL ID NO.: 131787

SCHOOL-BASED FEEDING PROGRAM

NFP DELIVERIES (SY 2021-2022)

Date No. of Packs Received
Grade Level Number of Beneficiaries Delivered New Replacement Total (New + No. of Packs for Replacement/ Rejected Remarks
Replacement)
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
TOTAL:

MILK DELIVERIES (SY 2021-2022)

No. of Packs Received
Date
Grade Level Number of Beneficiaries Total (New + No. of Packs for Replacement/ Rejected Remarks
Delivered New Replacement
Replacement)
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
TOTAL:

Prepared by: APPROVED BY:

RONNALIE J. REPONTE LEO D. VALLE

School Feeding Coordinator School Head