Department of Education

WASH IN SCHOOL MONITORING FORM

Instruction: Fill-up the spaces provided correctly and completely. This form shall be accomplished by the
School Head or any authorized representative from the school.

A. SCHOOL PROFILE

Date: __________________ School Year: _______________

Name of School: __________________________________________ School ID Number: ____________
District: _______________________________________ Division: ______________________________
Complete School Address: ______________________________________________________________
Name of School Head: _______________________________________ Contact No.: _______________

Total Enrolment:
Male Female Total
Shift 1
Shift 2
Shift 3

B. WATER ACCESS

1. Does the school provide safe drinking water?

All the time
Yes, but supply is not regular
No drinking water in school
2. Is the drinking water provided by the school for free? Yes No
3. What mechanisms are used to ensure learners have safe drinking water?
Teachers ask the learners to bring their own drinking water to school.
Safe water in refillable container are provided in designated areas within the school.
Water from an accessible water source is boiled.
Water from an accessible water source is filtered.
Others _________
4. In the previous week, how often is water for daily handwashing, bathing and cleaning of toilets
available in the school regardless of source? (Includes water delivered to the school or collected from
rain).
Available only on certain days of the week.
Available daily but only on certain hours.
Available daily for 24 hours.
5. Does the school coordinate with LGU or water district to test the quality of water? Yes No
6. How many times was the quality of water tested in current calendar year? _____________
DEPARTMENT OF EDUCATION
WASH IN SCHOOL MONITORING FORM

C. SANITATION

7. How many toilet seats are available for children / students in the school?
Do not include toilet seat for teachers.
Male Female Shared/Communal Total
Functional
Not functional

8. Are toilets secure, private and have door with lock? Yes No1.
Do toilets have lighting? Yes No3. Y
Do toilets have adequate ventilation? Yes No5. Ye
9. Do toilets for girls have wrapping materials for used sanitary pads? Yes No7. Yes
10. How many toilets for girls have washing facility inside the toilets? _______ Yes
11. Are detached toilets for girls within view of school building and people? Yes No es
12. Are there toilet/s designated for person with limited mobility? Yes No sN
(These toilets must have ramp, railing and adequate space for wheelchair)
N
o
13. How often are the sanitation facilities cleaned?
2. N
o
Daily Once a week
4. N
o
Y
At least twice a week Less than once a week
6. o
Ye
14. Does the school burn its waste? Yes No
8. Yes
15. Are segregated trash bins with cover available in the following areas?
Yes
Classrooms Offices Gardens
es
Toilets Clinics Hallways
sN
Canteens Play areas Gyms / Stage
N
o
16. Is waste segregation being practiced in school? Yes No
N
o
17. Does the school have policies / sanctions which promote the practice
N
o
of waste segregation? Yes No
o
18. How regular is garbage being collected from the school?
Daily Once a week No collection
2-3 times a week Less than once a week
19. Does the school have a compost pit for biodegradable waste? Yes No
20. Does the school have refuse pit for non-biodegradable waste? Yes No
21. Does the school have a materials recovery facility (MRF)? Yes No
22. Do all toilets in the school have functional septic tanks/s? All Some None
23. Does the school have a functional drainage from the kitchen and waste areas
to ensure that there is no stagnant water? Yes No
24. In the past year, did the school experience any floods? Yes No
25. Does the school adopt the following mechanisms to address the stagnant water?
Pumping out of water Soak pit
Filling of stagnant water Treatment of stagnant water to prevent
breeding of mosquitoes
26. Does the school have canteen? Yes No
27. Does the school canteen have sanitary permit? Yes No
DEPARTMENT OF EDUCATION
WASH IN SCHOOL MONITORING FORM

28. Do food handlers practice the following food safety measures?

Wearing
S of hairnet, gloves, masks and apron
t Handwashing
u Segregation of dry and wet food materials
29. Havedall food handlers been oriented on food safety measures? All Some None
e
30. Do all food handlers in the school have health certificates? All Some None
n
D. HYGIENEt
s
31. Howamany times in a week is group handwashing with soap conducted for all children in the school?
(onlyrfor elementary) _________
32. Whate is the extent of student participation in supervising group handwashing? (only for elementary)
a
Students are participants supervised by teachers
s S
ts Students S assist teachers in supervising handwashing activities
tui Students S are assigned to lead handwashing activities
33. Howudtgmany group handwashing facilities are available in the school? (count by increments of 10 water
outlets) eu
dn ____________
34. Whatdene is the total number of water outlets in all the group handwashing facilities? __________
ted
n
35. Is there a regular supply of soap for handwashing? Yes No
sn
tt
36. Are handwashing facilities with soap available in the following areas?
tsao
Classrooms
arsl S Toilets
S Canteen/Eating
S Areas
t Play eareS areas t Clinics S t Laboratories S
tu Agricultural reaaS u
areas (eg. Gulayan, livestock
t area) u
t
37. Do d
tu children ased d
perform individual handwashing
u the following times?
d
u
eu
d Before s
ahS meals e
d After using ed toilet
the
S
en i
s a cleaning activities n
e n
e the playground
td After t After S playing in
ten igsnS t
n tn
tu
stn igndS
After handling soil and animals s u
t
t st
38. How d d
tu
sate n egwmany times in a week is group as toothbrushing u with flouride as
conducted for all children in the
school? d
u ________ e
d
rsa ed na ra ra
39. What en is the extent of student participation inn
e supervising group
d
reta ed ts e
r er toothbrushing
en tn
ears Students to
dh S are participants supervised
ae by teachers ae
tn
seat Students ltoi S sa
assist teachers in supervising ts
toothbrushing activitiessa
ats as
srau Students e
l
o n are assigned to lead s
toothbrushing activities ss
ais t a S i
ra
is
40. Issetudthere e s
l a regular supply of toothbrush and toothpaste for toothbrushing? Yes No
rag dg g
er
41. Are siaed eu the eaa repair and maintenance requirements i ae for WASH facilities g
i reflected in the following:
rgnn ad hc n
g n
siaed e School improvement plan (SIP) sa g
a
h S e
n en
gn
sd
t Annual
n
e dt improvement plan (AIP) s
aets n ai S d
e d
42. What n
isstun t h are the sources of funds for WinS Supplies? is Please check e all that apply.
teats an
d dv t
d t
gisu
o d d w o School gi Private d LGU Children bring
tnsar ni
d t o
t PTA
gil ed a MOOE n
g donations Funds their own
o w
d lo l
etgnenear Soap t en o
leo a asw i el el
ed
alen
n tre Toothbrush h a
d
e ae
tetsase Toothpaste ase e t
d d d
ad
et asa sh
o
is a o
d
a
d
h s Cleaning n
i materials/supplies for toilets h t h
d
ao i
s
lt ra Repair and maintenance h S d lo d
ad
h g
i g
n
it a
h a
h
lnres ga
eo
n
el
n
aahn nu a a
eldeaig ac d
ae
d
an e
n
g gd n n
ad
ew sa tc w ad
d
n d
e ae d w
d
h
ad
w sn ti a
w
h
d
aw
t
aded n c a
DEPARTMENT OF EDUCATION
WASH IN SCHOOL MONITORING FORM

43. Where can learners avail of sanitary pads?

School
S Canteen Guidance
S Office Others
S
t School
S Clinic t Class Adviser/Teacher t
S
44. Is there
tu information on proper disposal
tu of sanitary napkins in the girls’
u toilet? Yes No
45. Areudthere DepEd Approved Instructional d materials on Menstrual Health for
u d
e
d
Teachers? ed e Yes No
n
46. Aree there DepEd Approved Information, en Education and Communications n
t
n
(IEC) materials on Menstrual Health ntfor Students? t Yes No
s
t s
t s
47. Is there a designated rest space/changing room for girls with menstrual
as sa a
discomfort? Yes No
ar ar r
re er e
E. DEWORMING ae ea a
as sa s
48. Is deworming
s done semi-annually? s s Yes No
49. What si is the total number of studentssi dewormed? i Yes No
ig gi g
gn gn n
F. HEALTHe EDUCATION e
n e
n
ed d
e d
50. Which td areas in the school have IEC materials t
d for WinS? t
to to Menstrual o
Hygiene Sanitation Food safety
l
o lo Health l
Bulletin el board le e
Classrooms ea ea a
Toilets d
a d
a d
Handwashing t
d facilities t
d t
Canteen/Eating to areas to o
o o o
51. Areot there organized structures (eg. TWGs, t
o student clubs) to promote tWinS? Yes No
52. Is WinS th a part of INSET? h
t h Yes No
b
h
53. Are learning materials available for teaching b
h WinS? b Yes No
r
b
54. Is WinS being advocated in the GPTCA assembly? r
b r Yes No
u
55. Areruthere planned and organized activities u
r for advocating WinS to parents /
su s
u s
stakeholders? Yes No
sh h
s h
56. Is WinS i
part of the co/extra-curricular program for students? i Yes No
h ih
n
i n
i n
g
n g
n g
Checked &gaEvaluated by: ag a
ca ca c
Printed Name & Signature: _______________________________________ Date: ___________
ct tc t
Position: ti ________________________________ it i
iv iv v
vi iv i
Certified True & Correct by: t
it it
Printed ti ti
Name & Signature: _______________________________________ i Date: ___________
ie ei School Head e
se es s
Position: s ________________________________ s