Republic of the Philippines

Province of Leyte
Municipality of Palo
Barangay __________
-oo0oo-

BNS MONTHLY REPORT

NAME OF BNS: ______________________________ Month of: _____________________

I. WEIGHT MONTHLY REPORTING

Age Group Male Female

0-28 days
29 days – 11 months
1-4 years old
5-9 years old
10-14 years old
7-9 years old

II. GARANTISADONG PAMBATA

NAME AGE HUSBAND NAME OF CHILD DEL. DATE ATTENDED BY: Del. at DELIVERED BY:
TYPE DEL.

III. TB SYMPTOMATICS (Case finding for the month only, sputum smear done) Pls.survey your purok monthly.

NAME AGE FAMILY HEAD FSN DATE

IV. IMMUNIZATION (Fully Immunized Child 9-12 months old, for the month only)
NAME OF CHILD BIRTHDATE MOTHER FSN DATE

V. EXCLUSIVE BREASTFEEDING CHILDREN (0-6 months old, for the month only)
NAME OF CHILD BIRTHDATE MOTHER FSN DATE
VI. LEPROSY (Case finding for the month only) “KETONG” BRING PATIENT TO RHU
NAME AGE FAMILY HEAD DATE

VII. DOGBITE (pls survey your purok weekly)

NAME AGE DATE BITTEN

VIII. DEATHS FOR THE MONTH ONLY ( in your purok only)

NAME AGE DATE OF DEATH CAUSE OF DEATH

VIII. FAMILY PLANNING

NAME AGE FAMILY PLANNING METHOD TYPE OF CLIENT

IX. DATE OF DUTY AND ACTIVITIES DONE AT CLINIC ASSIGNED

Submitted by: Checked by:

_________________________ __________________________
BHW RHM
Noted by: Approved by:

________________________ ___________________________
Barangay Captain Municipal Health Officer