Section A. Family Planning Services

Use of FP Method (Col. 1)	Current Users (Col. 2)				Section A. Family Planning Services New (End of Qtr) (Col. 3) Other (Present Qtr) Restarter (RS), Changing Method (CM), Changing Clinic (CC) (Col. 4)								Drop-outs(Present Quarter) (Col. 5)				Current Users (End of Quarter) (Col. 6)				New Acceptors (3 months of Present Qtr.) (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)	Eligible Population or Total Deliveries (Col. 2)	Age of Pregnant or Postpartum (Col 3) 10-14 No. % 15-19 No. % 20-49 No. %						Total No. (Col. 4) % (Col.4 / Eligible Population or Deliveries * 100) (Col. 5)		Interpretation (Col. 6)	Recommendations or Actions to be Taken (Col. 7)
B1. Prenatal Care
1.) Women who gave birth with at least 4 prenatal check-ups	Total deliveries: 0 10-14 15-19 20-49
2.) Pregnant women assessed of their nutritional status during the first trimester - Total	Eligible Population of 0-11 months
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

Indicators (Col. 1)	Eligible Population or Total Deliveries (Col. 2)	Age of Pregnant or Postpartum (Col 3) 10-14 No. % 15-19 No. % 20-49 No. %						Total No. (Col. 4) % (Col.4 / Eligible Population or Deliveries * 100) (Col. 5)		Interpretation (Col. 6)	Recommendations or Actions to be Taken (Col. 7)
16.) Deliveries attended by skilled health professionals - Total
16a.) Deliveries attended by a physicians
16b.) Deliveries attended by nurses
16c.) Deliveries attended by midwives
17.) Facility-based deliveries - Total
17a.) Deliveries in public health facility
17b.) Deliveries in private health facility
18.) Vaginal deliveries	Total deliveries: 0 10-14 15-19 20-49
19.) Deliveries by cesarean section
20.) Full-term births	Total Deliveries:
21.) Pre-term births
22.) Fetal deaths
23.) Abortion/miscarriage
B3. Postpartum and Newborn Care
1.) Women who gave birth with at least 4 prenatal check-ups	Total deliveries: 0 10-14 15-19 20-49
1.) Women who gave birth with at least 4 prenatal check-ups	Eligible Population 0-11 months
1.) Women who gave birth with at least 4 prenatal check-ups

Section C. Child Care and Services

Indicators (Col. 1)	Eligible Population or Total Deliveries (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1.) BCG	Eligible Population of 0-11 months
2.) Hepatitis B, within 24 hours after birth
3.) CPAB

Indicators (Col. 1)	Eligible Population or Total Deliveries (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
4.) DPT-HiB-HepB 1	Eligible Population of 0-11 months
5.) DPT-HiB-HepB 2
6.) DPT-HiB-HepB 2
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	Eligible Population 0-12 months
17.) FIC
18.) CIC	Eligible Population 0-12 month
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
25.) Newborns initiated on breastfeeding within 1 hour afte birth	Total Live Births
26.) Preterm/LBW infants given iron supplementation	Total Live Births with Low Birth Weight
27.) Infants exclusively breastfed until 5th month and 29 days	Eligible Population 0-6 months

Indicators (Col. 1)	Eligible Population or Total Deliveries (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population or Seen * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
28.) Infants who continued breastfeeding and were introduced to complementary feeding beginning at 6 months of age	Eligible Population of 6-11 months
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.	Eligible Population of 12-59 months
31.) Infants 6-11 months old who completed MNP or Lipid-Based Nutrient Supplement – Small Quantity (LNS-SQ) supplementation	Eligible Population of 6-11 months
32.) Children 12-23 months old who completed MNP or Lipid-Based Nutrient Supplement – Small Quantity (LNS-SQ) supplementation	Eligible Population of 12-23 months
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 SFPP
33d.) MAM children 0-59 months died in SFP
33e.) MAM children 0-59 months dischaged 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
C4. Management of Sick Infants and Children
36.) CPAB	None
37.) CPAB	None
38.) CPAB	None

Section D. Oral Health Care and Services

Indicators (Col. 1)	Eligible Population * Services Target (ST) o Clients Examined (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population or Clients Examined * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
1.) Children 12-59 months old who are orally fit upon oral examination or after oral rehabilitation	Eligible Population of 12-59 months 20% ST.*
2.) Clients 5 years old and above examined
2a.) 5 yeas old and above with cases of Decayed-Missing Filled Teeth (DMFT)
3.) Infants 0-11 months old who received Basic Oral Health Care (BOHC)	Eligible Population of 0-11 months 30% ST.*
4.) Children 1-4 years old who received BOHC	Eligible Population of 1-4 years old 30% ST.*
5.) Children 5-9 years old who received BOHC	Eligible Population of 5-9 years old 30% ST.*
6.) Adolescents 10-14 years old who received BOHC	Eligible Population of 10-14 years 30% ST.*
7.) Adolescents 15-19 years old who received BOHC	Eligible Population of 15-19 years old 30% ST.*
8.) Adults 20-59 years old who received BOHC	Eligible Population of 20-59 years old 30% ST.*
9.) Senior citizens 60 years old and above who received BOHC	Eligible Population of 60 yeas old and above 30% ST.*
10.) Pregnant women 10-14 years old who received BOHC	Eligible Population of 0-11 months
11.) Pregnant women 155-19 years old who received BOHC
12.) Pregnant women 20-49 years old who received BOHC

Section E. Non-Communicable Disease
Prevention and Control Services

Indicators (Col. 1)	Eligible Population or Risk assessed using the PhilPEN protocol (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population or Risk-assessed* 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
E1. Lifestyle Related
1.) 20-50 years old who were risk assessed using the PhilPEN potocol	Eligible Population of 20-59 years old

Indicatorrs (Col. 1)	Eligible Population or Risk assessed using the PhilPEN prrotocol (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population or Risk-assessed or Identified * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
1a.) Current smokers 20-59 years old	Risk assessed using the PhilPEN protocol
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	Eligible Population 60 years old and above:
2a.) Current smokers 60 years old and above	Risk assessed using the PhilPEN protocol
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)
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	None
6.) 20 yeas old and above with suspicious breast mass	Total number of women 20 years old and above screened for 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	Total number of identified hypertensive 20-59 years old
9.) Identified hypertensive 60 yeas old and above
10.) Identified hypertensive 60 yeas old and above provided with antihypertensive medications	Total number of identified hypertensive 60 years old and above
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	Total number of identified Type 2 Diabetes Mellitus 20-59 years old
13.) Identified with Type 2 Diabetes Mellitus 60 yeas old and above
14.) Identified with Type 2 Diabetes Mellitus 60 yeas old and above provided with diabetes medications	Total number of identified Type 2 Diabetes Mellitus 60 years old and above
E5. Blindness Prevention Program
15.) 60 years old and above screened for visual acuity	Eligible Population 60 years old and above
16.) 60 years old and above diagnosed with eye disease/s

Indicators (Col. 1)	Eligible Population (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
17.) 60 years old above who received 1 dose of Pneumococcal Polysaccharide Vaccine (PPV)	Eligible Population of 60 years old and above
18.) 60 years old and above who received 1 dose of influenza vaccine

Section F. Infectious Disease Prevention
and Control Services

Indicators (Col. 1)	Seen or Eligible Population (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Seen or Eligible Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
F1. Filariasis (to be reported annually)
F2. Schistosomiasis Prevention and Control
1.) Patients seen	None
2.) Suspected cases seen	Total number of patients seen
3.) Acute clinically diagnosed cases seen	Total number of suspected cases seen
4.) Acute confirmed cases	Total number of acute clinically diagnosed cases
5.) Confirmed chronic cases	Total number of chronic clinically diagnosed cases
6.) Confirmed cases (acute and chronic) - Total	None
7.) Chronic clinically diagnosed cases seen	Total number of suspected cases seen
8.) Chronic clinically diagnosed cases treated	Total number of confirmed cases (acute and chronic)
9.) Confirmed chronic cases referred to a hospital facility	Total number of confirmed chronic cases
F3. Soil Transmitted Helminthiasis Prevention and Control
10.) 12-59 months old who completed 2 dose of deworming tablet	Eligible Population 12-59 months
11.) 5-9 years old who completed 2 dose of deworming tablet	Eligible Population 5-9 years old
12.) 10-19 years old who completed 2 dose of deworming tablet	Eligible Population 10-19 years old
13.) WRA 20-49 years old who completed 2 dose of deworming tablet	Eligible Population 20-49 years old (female only)
14.) Pregnant women who completed 1 dose of deworming tablet	Eligible Population 0-11 months

Indicatorrs (Col. 1)	Eligible Population or Total Population (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population or Total Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
F4. HIV-AIDS/STI Prevention and Control
15.) Pregnant women screened for syphilis	Eligible Population 0-11 months
16.) Pregnant women tested positive for syphilis	Total number of pregnant women screened for syphilis
17.) Pregnant women tested for HIV	Eligible Population 0-11 months
F5. Leprosy Prevention and Control
18.) Leprosy cases on treatment during reporting period (Leprosy Prevalence Rate)	Total Population:
19.) Newly detected cases during reporting period (Case Detection Rate)
F6. Rabies Prevention and Control
20.) Animal Bites	None
21.) Deaths due to Rabies	Total number of Animal Bites

Section G. Environmental Health and
Sanitation Services

Indicators (Col. 1)	Estimated Household (Col. 2)	Total (Col. 3)	% (Col.3 / Estimated Household * 100) (Col. 4)	Interpretation (Col. 5)	Recommendations or Actions to be Taken (Col. 6)
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
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

Indicators (Col. 1)	Number of municipalities and chartered cities (Col. 2)	Total (Col. 3)	% (Col.3 / Col.2 * 100) (Col. 4)	Interpretation (Col. 5)	Recommendations or Actions to be Taken (Col. 6)
G3. Zero Open Defecation (ZOD)
3.) Municipalities and chartered cities certified as ZOD area

Section H. Mortality

Indicators (Col. 1)	Live Births (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
1.) Maternal Deaths	Total Live Births
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)	Live Births (Col. 2)	Counts Male (Col. 3) Female (Col. 4) Total (Col. 5) % (Col.5 / Eligible Population * 100) (Col. 6)				Interpretation (Col. 7)	Recommendations or Actions to be Taken (Col. 8)
1.) Live births
2.) Live births among 15-19 years old women

Date From:
Date To:
Barangay
Form

Section A. Family Planning Services

Section B. Maternal Care and Services

Section C. Child Care and Services

Section D. Oral Health Care and Services

Section E. Non-Communicable Disease Prevention and Control Services

Section F. Infectious Disease Prevention and Control Services

Section G. Environmental Health and Sanitation Services

Section H. Mortality

Section I. Natality

Section E. Non-Communicable Disease
Prevention and Control Services

Section F. Infectious Disease Prevention
and Control Services

Section G. Environmental Health and
Sanitation Services