For submission to RHU/MHC

Section A. Family Planning Services

A1.b. Use of FP Method

(Col. 1)

Current Users
(Beginning Month)

(Col. 2)

Section A. Family Planning Services

New
(Previous Month)

(Col. 3)

Other (Present Month)

Restarter (RS), Changing Method (CM), Changing Clinic (CC)

(Col. 4)

Drop-outs (Present Month)

(Col. 5)

Current Users 
(End of Month)

(Col. 6)

New Acceptors
(Present Month)

(Col. 7)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total
1.) FSTR/BTL
2.) MSTR/NSV
3.) Condom
4.) Pills - Total
4a.) Pills-POP
4b.) Pills-COC
5.) Injectables (DMPA/POI)
6.) Implants
7.) IUD - Total
7a.) IUD - Interval
7b.) IUD - Postpartum
8.) NFP-LAM
9.) NFP-BBT
10.) NFP-CMM
11.) NFP-STM
12.) NFP-SDM
13.) Total Current Users

Section B. Maternal Care and Services

Indicators

(Col. 1)

Age

(Col 2)

10-14

15-19

20-49

Total

(Col 3)

Remarks

(Col. 4)
B1. Prenatal Care
1.) Women who gave birth with at least 4 prenatal check-ups
2.) Pregnant women assessed of their nutritional status during the first trimester - Total
2a.) Pregnant women with normal BMI
2b.) Pregnant women with normal BMI
2c.) Pregnant women with normal BMI
3.) Pregnant women with normal BMI
4.) Pregnant women with normal BMI
5.) Pregnant women with normal BMI
6.) Pregnant women with normal BMI
7.) Pregnant women with normal BMI
8.) Pregnant women with normal BMI
9.) Pregnant women with normal BMI
10.) Pregnant women with normal BMI
11.) Pregnant women with normal BMI
12.) Pregnant women with normal BMI
13.) Pregnant women with normal BMI
B2. Intrapartum Care and Delivery Outcome
14.) Deliveries
15.) Live births - Total
15a.) Live births with normal birth weight
15b.) Live births with low birth weight
15c.) Live births with unknown birth weight
16.) Deliveries attended by skilled health professionals - Total
16a.) Deliveries attended by a physicians
16b.) Deliveries attended by nurses
16c.) Deliveries attended by midwives

Indicators

(Col. 1)

Age

(Col 2)

10-14

15-19

20-49

Total

(Col 3)

Remarks

(Col. 4)
17.) Facility-based deliveries - Total
17a.) Deliveries in public health facility
17b.) Deliveries in private health facility
18.) Vaginal deliveries
19.) Deliveries by cesarean section
20.) Full-term births
21.) Pre-term births
22.) Fetal deaths
23.) Abortion/miscarriage
B3. Postpartum and Newborn Care
24.) Postpartum women together with their newborn who completed at least 2 postpartum check-ups
25.) Postpartum women who completed iron with folic acid supplementation
26.) Postpartum women with Vitamin A supplementation

Section C. Child Care and Services

Indicators

(Col. 1)

Male

(Col. 2)

Female

(Col. 3)

Total

(Col. 4)

Remarks

(Col. 5)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1.) BCG
2.) Hepatitis B, within 24 hours after birth
3.) CPAB
4.) DPT-HiB-HepB 1
5.) DPT-HiB-HepB 2
6.) DPT-HiB-HepB 3
7.) OPV 1
8.) OPV 2
9.) OPV 3
10.) IPV 1
11.) IPV 2
12.) PCV 1
13.) PCV 2
14.) PCV 3
15.) MCV 1
16.) MCV 2
17.) FIC
18.) CIC
19.) Eligible Grade 1 Learners Enrolled
20.) Td, Grade 1
21.) Measles Rubella, Grade 1
22.) Eligible Grade 7 Learners Enrolled
23.) Td, Grade 7
24.) Measles Rubella, Grade 7
C2. Nutrition Services for Infants and Children
24.) Measles Rubella, Grade 7
25.) Newborns initiated on breastfeeding within 1 hour after birth
26.) Preterm/LBW infants given iron supplementation
27.) Infants exclusively breastfed until 5th month and 29 days
28.) Infants who continued breastfeeding and were introduced to complementary feeding beginning at 6 months of age
29.) Infants 6-11 months old given 1 dose of Vitamin A 100,000 I.U.
30.) Children 12-59 months old given 2 doses of Vitamin A 200,000 I.U.
31.) Infants 6-11 months old who completed MNP or Lipid-Based Nutrient Supplement – Small Quantity (LNS-SQ) supplementation
32.) Children 12-23 months old who completed MNP or Lipid-Based Nutrient Supplement – Small Quantity (LNS-SQ) supplementation
33.) MAM children 0-59 months enrolled in Supplementary Feeding Program (SFP)
33a.) MAM children 0-59 months identified
33b.) MAM children 0-59 months cured in SFP
33c.) MAM children 0-59 months defaulted in SFP
33d.) MAM children 0-59 months died in SFP
33e.) MAM children 0-59 months discharged in SFP
34.) SAM children 0-59 months without complication admitted in Out-Patient Therapeutic Center (OTC)
34a.) SAM children 0-59 months identified in OTC
34b.) SAM children 0-59 months without complication cured in OTC
34c.) SAM children 0-59 months without complication defaulted in OTC
34d.) SAM children 0-59 months without complication died in OTC
34e.) SAM children 0-59 months discharged in OTC
C3. Management of Sick Infants and Children
35.) Sick Infants 6-11 months old seen
36.) Sick Infants 6-11 months old received Vitamin A
37.) Sick Children 12-59 months old seen
38.) Sick Children 12-59 months old received Vitamin A
39.) Acute Diarrhea cases 0-59 months old seen
40.) Diarrhea cases 0-59 months old received oral rehydration salt solution (ORS)
41.) Diarrhea cases 0-59 months old received ORS and zinc
42.) Pneumonia cases 0-59 months old seen
43.) Pneumonia cases 0-59 mos. old received treatment

Section D. Oral Health Care and Services

Indicators

(Col. 1)

Male

(Col. 2)

Female

(Col. 3)

Total

(Col. 4)

Remarks

(Col. 5)
1.) Children 12-59 months old who are orally fit upon oral examination or after oral rehabilitation
2.) Clients 5 years old and above examined
3.) Infants 0-11 months old who received Basic Oral Health Care (BOHC)
4.) Children 1-4 years old who received BOHC
5.) Children 5-9 years old who received BOHC
6.) Adolescents 10-14 years old who received BOHC
7.) Adolescents 15-19 years old who received BOHC
8.) Adults 20-59 years old who received BOHC
9.) Senior citizens 60 years old and above who received BOHC
10.) Pregnant women who received BOHC

Section E. Non-Communicable Disease
Prevention and Control Services

Indicators

(Col. 1)

Male

(Col. 2)

Female

(Col. 3)

Total

(Col. 4)

Remarks

(Col. 5)
E1. Lifestyle Related
1.) 20-50 years old who were risk assessed using the PhilPEN potocol
1a.) Current smokers 20-59 years old
1b.) Binge drinkers 20-59 years old
1c.) Overweight or obese 20-59 years old
2.) 60 years old and above who were risk assessed using the PhilPEN protocol
2a.) Current smokers 60 years old and above
2b.) Binge drinkers 60 years old and above
2c.) Overweight or obese 60 years old and above
E2. Cancer Prevention and Control
3.) 20 years old and above screened for cervical cancer using Visual Inspection with Acetic Acid (VIA) or Pap Smear
4.) 20 years old and above found positive or suspect for cervical cancer using VIA or Pap Smear
5.) 20 years old and above screened for breast mass
6.) 20 years old and above with suspicious breast mass
E3. Cardiovascular Disease Prevention and Control
7.) Identified hypertensive 20-59 years old
8.) Identified hypertensive 20-59 years old provided with antihypertensive medications
9.) Identified hypertensive 60 years old and above
10.) Identified hypertensive 60 years old and above provided with antihypertensive medications
E4. Diabetes Mellitus Prevention and Control
11.) Identified with Type 2 Diabetes Mellitus 20-59 years old
12.) Identified with Type 2 Diabetes Mellitus 20-59 years old provided with diabetes medications
13.) Identified with Type 2 Diabetes Mellitus 60 years old and above
14.) Identified with Type 2 Diabetes Mellitus 60 years old and above provided with diabetes medications
E5. Blindness Prevention Program
15.) 60 years old and above screened for visual acuity
16.) 60 years old and above diagnosed with eye disease/s
E6. Immunization for Senior Citizens
17.) 60 years old above who received 1 dose of Pneumococcal Polysaccharide Vaccine (PPV)
18.) 60 years old and above who received 1 dose of influenza vaccine

Section F. Infectious Disease Prevention
and Control Services

Indicators

(Col. 1)

Male

(Col. 2)

Female

(Col. 3)

Total

(Col. 4)

Remarks

(Col. 5)
F1. Filariasis (to be reported annually)
F2. Schistosomiasis Prevention and Control
1.) Patients seen
2.) Suspected cases seen
3.) Acute clinically diagnosed cases seen
4.) Acute confirmed cases
5.) Confirmed chronic cases
6.) Confirmed cases (acute and chronic) - Total
7.) Chronic clinically diagnosed cases seen
8.) Chronic clinically diagnosed cases treated
9.) Confirmed chronic cases referred to a hospital facility
F3. Soil Transmitted Helminthiasis Prevention and Control
10.) 12-59 months old who completed 2 dose of deworming tablet
11.) 5-9 years old who completed 2 dose of deworming tablet
12.) 10-19 years old who completed 2 dose of deworming tablet
13.) WRA 20-49 years old who completed 2 dose of deworming tablet
14.) Pregnant women who completed 1 dose of deworming tablet
F4. HIV-AIDS/STI Prevention and Control
15.) Pregnant women screened for syphilis
16.) Pregnant women tested positive for syphilis
17.) Pregnant women tested for HIV
F4. Leprosy Prevention and Control
18.) Leprosy cases on treatment during reporting period (Leprosy Prevalence Rate)
19.) Newly detected cases during reporting period (Case Detection Rate)
F6. Rabies Prevention and Control
20.) Animal bites
21.) Deaths due to Rabies

Section G. Environmental Health and
Sanitation Services

Indicators

(Col. 1)

Total

(Col. 2)

Remarks

(Col. 3)
G1. Water
1.) Households (HHs) with access to improved water supply - Total
1a.) HHs with Level I
1b.) HHs with Level II
1c.) HHs with Level III
1d.) HHs using safely managed drinking-water services
G2. Sanitation
2.) HHs with Basic Sanitation Facility - Total
2a.) HHs with pour/flush toilet connected to septic tank
2b.) HHs with pour/flush toilet connected to community sewer/sewerage system or any other approved treatment system
2c.) HHs with Ventilated Improved Pit (VIP) Latrine
2d.) HHs using safely managed sanitation services

Section H. Mortality

Indicators

(Col. 1)

Male

(Col. 2)

Female

(Col. 3)

Total

(Col. 4)

Remarks

(Col. 5)
1.) Maternal Deaths
2.) Under-five Deaths
3.) Infant Deaths
4.) Neonatal Deaths
5.) Perinatal Deaths - Total
5a.) Fetal Deaths
5b.) Early Neonatal Deaths

Section I. Natality

Indicators

(Col. 1)

Male

(Col. 2)

Female

(Col. 3)

Total

(Col. 4)

Remarks

(Col. 5)
1.) Live births
2.) Live births among 15-19 years old women