Republic of the Philippines

Department of Education
Region XIII Caraga
Division of Agusan Del Sur
Datu Lipus Makapandong National High

Contextualized Self Evaluation Checklist for Classroom Essentials

(for all Advisers / office /laboratory incharge)
Directions :
Please check the column YES if the indicator is available & No if there is none. If you check No please
indicate the reason and the date to comply in the Remarks" column and also mark N/A if the indicator is
not applicable.

1. Front Area Yes No Remarks

1 Building trash bins w/ labels (4pcs)

2 Group handwashing facility(GHWF) w/ H20, soap
3 GHWF ground with limestone
4 Front ground free from trash & swamp
5 Front ground landscaped & w/ flowers
6 Hall ceiling free from cobwebs
7 Clear gutters

2. Classroom Yes None Remarks

1 Door w/ padlock
2 Label- grade, section, office

3
Door w/ teacher & Class programs( framed or laminated)
4 Handwashing facility w/ soap & water
5 Medicine kit

6 Health corner/WINS corner has mirror, comb, finecomb,

and learner's health kit (deodorant, tooth brush ,
toothpaste, soap, napkin, towel,cotton, comb, etc.)
7 Potable water w/ clean glasses
8 WINS IEC
9 WINS booklets ( 3 pcs per booklet)

10 Divan w/ the ff. cleaning materials (4 pcs rugs, 5 pcs scrub, 5

pcs stickbroom, 5 pcs silhig lanot, wax )
11 Ceiling free from cobwebs
12 4 sets of trashbins with labels
13 Floors -waxed , free from dusts
14 Classroom walls & ceiling repainted
15 Chalkboard & chalkledge repainted & repaired
16 Chairs repainted with chocolate brown , arranged
 17 Teachers table , chair , cabinets repainted or varnished with
arranged things
18 potted plants
19 Menstrual Health Management (MHM) Rest Area
20 Classroom Trashbins (4pcs with label)
Sub -Total page 1

3. WINDOWS Yes None Remarks

1 No broken window jalousies
2 Window jambs & blades are wiped ( free from dusts)

3 If there are curtains , it should be short enough or just

valance
4 Presence of rugs for windows

4. Comfort Room Yes None Remarks

1 Label at the door
2 Doors are with locks(inside & outside)
3 1- 3 potted plants & Albatross

4
Cleaning materials - broomstick , brush , dustpan , soap
5 Two pcs trashbins w/ labels
6 Two pcs dipper or "Kabo' & small pail

6 Two pcs big pail w/ water ( for big CR's), 1 pail for 1
CR/small)
7 Sanitary pads,used sanitary pad wrapper
8 with mirror, Chair (rest area for female CR if there is enough space)
9 Ceiling & walls repainted & free from cobwebs
10 Well- lighted & ventilated
11 Rug - at the entrance/door

5.Back & Sides of the Classroom Yes None Remarks

1 Back & sides are planted or landscaped if possible
2 swampy areas are filled w/ limestone
3 Cleaned, planted & free from hazardous objects
4 Compost pile
5 Façade- cleared and painted

6. Assigned Garden & Ground Areas Yes None Remarks

1 Cleaned
2 Planted
3 Maintained
4 Blooming
Total page 2
Grand Total
Evaluated by :

Adviser - Grade _____

Submitted to:
 Mentor
Noted :

MARIA MAGDALINA Q. SENTONES

Principal III
 Republic of the Philippines
Department of Education
Region XIII Caraga
Division of Agusan Del Sur
Datu Lipus Makapandong National High

Contextualized Self Evaluation Checklist for

Classroom Essentials with WinS Integration
(for Adviser/ Office/ Laboratory Incharge)
Directions :
Please check the column YES if the indicator is available & No if there is none. If you check No please
indicate the reason and the date to comply in the Remarks" column and also mark N/A if the indicator is
not applicable.

1. Front Area Yes No Remarks

1 Building trash bins w/ labels (4pcs)

Group handwashing facility(GHWF) w/ Water, soap,
2 Drainage
3 Front ground free from trash & swamp
4 Front ground landscaped & w/ flowers
5 Hall ceiling free from cobwebs
6 Clear gutters

2. Classroom Yes None Remarks

1 Door w/ padlock
2 Label- grade, section, office

3 Door w/ Teacher & Class programs( framed or laminated) -

with indicated Handwashing and toothbrushing activity
4 Handwashing facility w/ soap , water, IEC, Functional
Drainage, Schedule of Cleaning
5 Medicine kit

6 Health corner/WINS corner has mirror, comb, finecomb,

and learner's health kit (deodorant, tooth brush ,
toothpaste, soap, napkin, towel,cotton, comb, etc.)
7 Potable water w/ clean glasses (if possible students has
water tumbler)
8 WINS IEC
9 WINS booklets ( 3 pcs per booklet)

10 Divan w/ the ff. cleaning materials (4 pcs rugs, 5 pcs scrub, 5

pcs stickbroom, 5 pcs silhig lanot, wax )
11 Ceiling free from cobwebs
12 4 sets of trashbins with cover and labels- Segregated
 13 Hard Copy of ESWM Policy and SSG resolution
14 Floors -waxed , free from dusts
15 Classroom walls & ceiling repainted
16 Chalkboard & chalkledge repainted & repaired
17 Chairs repainted with chocolate brown , arranged

18 Teachers table , chair , cabinets repainted or varnished with

arranged things
19 potted plants
20 Menstrual Health Management (MHM) Rest Area

21 Systematic Flow of Handwashing and Toothbrushing

Activity lead by Students
Sub -Total

3. WINDOWS Yes None Remarks

1 No broken window jalousies
2 Window jambs & blades are wiped ( free from dusts)

3 If there are curtains , it should be short enough or just

valance
4 Presence of rugs for windows

4. Comfort Room Yes None Remarks

1 Label at the door
2 Doors are with locks(inside & outside)
3 Functional Floor Drainage
4 Functional Septic Tank
5 Schedule of Cleaning
6 1- 3 potted plants & Albatross

7
Cleaning materials - broomstick , brush , dustpan , soap
8 Two pcs trashbins w/ labels
9 Two pcs dipper or "Kabo' & small pail

10 Two pcs big pail w/ water ( for big CR's), 1 pail for 1
CR/small)
11 Sanitary pads,used sanitary pad wrapper
12 with mirror, Chair (rest area for female CR if there is enough space)
13 Ceiling & walls repainted & free from cobwebs
14 Well- lighted & ventilated
15 Rug - at the entrance/door

5.Back & Sides of the Classroom Yes None Remarks

1 Back & sides are planted or landscaped if possible
2 swampy areas are filled w/ limestone
3 Cleaned, planted & free from hazardous objects
4 Compost pile
5 No Traces of Burning
6 No Stagnant Water
7 rain Water Collector

6. Assigned Garden & Ground Areas Yes None Remarks

6. Assigned Garden & Ground Areas Yes None Remarks
1 Cleaned
2 Planted
3 Maintained
4 Blooming

7 WinS Capacity Building Yes None Remarks

IPC MOOC Certificate
Total
Grand Total
Evaluated by :

Adviser - Grade _____

Submitted to:

Mentor
Noted :

MARIA MAGDALINA Q. SENTONES

Principal III
 Republic of the Philippines
Department of Education
Region XIII Caraga
Division of Agusan Del Sur
Datu Lipus Makapandong National High

Contextualized Self Evaluation Checklist for

Canteen with WinS Integration
Directions :
Please check the column YES if the indicator is available & No if there is none. If you check No please
indicate the reason and the date to comply in the Remarks" column and also mark N/A if the indicator is
not applicable.

Canteen Yes No Remarks

1 Potable water w/ clean glasses

2 Handwashing Facility with Soap, Water, and Functional Drainage
3 IEC on Canteen Food Guidelines
4 WINS IEC
Potable water w/ clean glasses (if possible students has
5 water tumbler)
6 WINS IEC
7 4 sets of trashbins with cover and labels- Segregated
8 Hard Copy of ESWM Policy and SSG resolution
9 Canteen Sanitary Permit
10 Compiled Health Certificate of All Food Handlers
11 Sanitary Pads

A. Comfort Room Yes None Remarks

1 Label at the door
2 Doors are with locks(inside & outside)
3 Functional Floor Drainage
4 Functional Septic Tank
5 Schedule of Cleaning
6 1- 3 potted plants & Albatross

7
Cleaning materials - broomstick , brush , dustpan , soap
8 Two pcs trashbins w/ labels
9 Two pcs dipper or "Kabo' & small pail
11 Sanitary pads,used sanitary pad wrapper
13 Ceiling & walls repainted & free from cobwebs
14 Well- lighted & ventilated
15 Rug - at the entrance/door
 B. Back & Sides of the Classroom Yes None Remarks
1 Back & sides are planted or landscaped if possible
2 swampy areas are filled w/ limestone
3 Cleaned, planted & free from hazardous objects
4 Cleaned, planted & free from hazardous objects
5 No Traces of Burning
6 No Stagnant Water

Total
Grand Total
Evaluated by :

_______ Canteen In-charge

Submitted to:

Mentor
Noted :

MARIA MAGDALINA Q. SENTONES

Principal III