Fhsisver2012 EditedSept162013 PDF

Field Health Services
Information System
————————————————
FHSIS VER. 2012
Public Health Surveillance and Informatics Division

National Epidemiology Center
Department of Health
Manila, Philippines
Message from the Director
The Field Health Services Information System (FHSIS) continues to

strengthen its goal for evidence-based decision-making at all levels of the
health management systems. FHSIS ver 2012 updates the Department of
Health’s core health indicators, recording and reporting forms for better doc-
umentation. These data shall be utilized for policy directions and systems
improvement. This huge endeavour was made possible through the efforts
and collaboration with the National Epidemiology Center, National Center
for Disease Prevention and Control, Centers for Health Development and
the National Statistics Office.
Operational since 1989, FHSIS has been the official system of the DOH
and designated as national health statistics as per Executive Order 352 and
provides health services data to monitor activities in each of these programs
on routine basis (monthly, quarterly or annually) from the Barangay Health
Stations, municipality, province, cities and regions.
I am proud to present this update to enhance the data quality of the

Field Health Services Information System.
ENRIQUE A. TAYAG, MD, FPSMID, PHSAE, CESO III

Director IV
i
EDITORIAL BOARD
Enrique A. Tayag MD, PHSAE, FPSMID, CESO III

Director IV, NEC
Vito G. Roque, Jr. RMT, MD, PHSAE

Medical Specialist IV
Public Health Surveillance & Informatics Division, NEC
Vikki Carr D. de los Reyes, MD, PHSAE

Medical Specialist III
FHSIS National Coordinator, NEC
Jose M. Hernaez
Information Systems Analyst III, NEC
Joel V. Cantero
Computer Programmer III, NEC
Levi L. Lameda, RN
Nurse II, NEC
Kristine Dianne T. Toledo, RN

Nurse I, NEC
Francis Raize Nicholas Bautista, RN

Nurse I, NEC

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ACKNOWLEDGEMENTS
Program Managers
Dr. Florencia Apale Mr. Edgardo Erce

Family Planning Program, NCDPC Soil Transmitted Helminthiasis Control
Program, IDO, NCDPC
Dr. Juanita Basilio
Family Health Office, NCDPC Dr. Francesca Gajete
Leprosy Program, IDO, NCDPC
Dr. Mario Baquilod
Malaria Control Program, IDO, NCDPC Dr. Leda Hernandez
Filariasis Program, IDO, NCDPC
Dr. Gerard Bellimac
National AIDS and STI Prevention and Control Ms. Liberty Importa
Program (NASPCP), IDO, NCDPC Nutrition Program, FHO, NCDPC
Dr. Anthony Calibo Ms. Ruth Martinez

Newborn Care, FHO, NCDPC Schistosomiasis Program, IDO, NCDPC
Dr. Manuel Calonge Engr. Joselito Riego de Dios

Dental Program, FHO, NCDPC Environmental Program, NCDPC
Dr. Anthony Cu Dr. Genesis Samonte

National TB Program, IDO, NCDPC HIV Surveillance, NEC
Ms. Frances Precilla Cuevas Engr. Roland Santiago

Non-Communicable Disease Program, DDO, Environmental Program, NCDPC
NCDPC
Dr. Rosalind Vianzon
Dr. Diego Danila National TB Program, IDO, NCDPC
Maternal Care Program, FHO, NCDPC
Dr. Ernesto Eusebio S. Villalon
Dr. Joyce Ducusin Leprosy Program, IDO, NCDPC
EPI Program, FHO, NCDPC
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Regional FHSIS Coordinators

Ms. Myrna Gurtiza Mr. James Valencia
Statistician III Statistician II
CHD - Ilocos CHD - Zamboanga Peninsula
Dr. Marian Lynn de Laza Ms. Gloria Rodriguez

Medical Specialist III Statistician III
CHD - Cagayan Valley CHD - Northern Mindanao
Ms. Luz Campos Engr. Ma. Elizabeth Baba

Statistician III Statistician III
CHD - Central Luzon CHD - Davao
Mr. Mariano Selorio Jr. Mr. Leonardo Bautista

CHD - CALABARZON CHD - Central Mindanao
Ms. Genoveva Viñas Ms. Maria Angeles de Guzman

Statistician II Statistician III
CHD - MIMAROPA CHD - CAR
Ms. Suenia Loria Mr. Paulito Ofiasa, RN

CHD - Bicol CHD - CARAGA
Ms. Alma Dumasis Ms. Maria Luz dela Cuadra

CHD - Western Visayas CHD - Metro Manila
Ms. Hermela Tan Ms. Delia Ramos

Nurse III Statistician II
CHD - Central Visayas DOH-ARMM
Ms. Lilia Mariano

Statistician III
CHD - Eastern Visayas
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Contents

Message ……………………………………………………………………………………………………………………………………….... i
Editorial Board ………………………………………………………………………………………………………………………………… ii
Acknowledgements………………………………………………………………………………………………………………………….. iii
Contents v
Acronyms……………………………………………………………………………………………………………………………………….... ix

Chapter 1 - Introduction

1.1 Introduction………………………………………………………………………………………………………………………… 2
1.2 Objectives of FHSIS revision………………………………………………………………………………………………… 3
1.3 Principles of FHSIS version 2012………………………………………………………………………………………….. 3
1.4 Components of FHSIS version 2012…………………………………………………………………………………….. 3

Chapter 2 - Components of FHSIS

2.1 Recording Tools………………………………………………………………………………………………………………….. 5
2.1.1 Individual Treatment Record (ITR) ……………………………………………………………………………. 5
2.1.2 Target Client List (TCL) ………………………………………………………………………………………………. 5
2.1.3 Summary Table (ST) ………………………………………………………………………………………………….. 6
2.1.4 Monthly Consolidation Table (MCT) ………………………………………………………………………….. 6

2.2 Reporting Tools…………………………………………………………………………………………………………………… 6
2.2.1 The Monthly Forms……………………………………………………………………………………………………. 7
2.2.1.1 Program Report (M1) ………………………………………………………………………………………. 7
2.2.1.2 Morbidity Report (M2) …………………………………………………………………………………….. 7

2.2.2 The Quarterly Forms………………………………………………………………………………………………….. 7
2.2.2.1 Program Report (Q1) ……………………………………………………………………………………….. 7
2.2.2.2 Morbidity Report (Q2) ……………………………………………………………………………………… 7

2.2.3 The Annual Forms (A‐BHS, A1, A2, A3) ……………………………………………………………………… 7

2.3 Recording and Reporting Tools Guide…………………………………………………………………………………. 8

2.4 Reporting Flow……………………………………………………………………………………………………………………. 9

2.5 Target Client List for Prenatal Care……………………………………………………………………………………… 10

2.6 Target Client List for Post‐partum Care……………………………………………………………………………….. 17

2.7 Target Client List for Family Planning………………………………………………………………………………….. 20

2.8 Target Client List for Nutrition and Expanded Program for Immunization Part 1………………… 27

2.9 Target Client List for Nutrition and Expanded Program for Immunization Part 2………………… 29

2.10 Target Client List for Sick Children……………………………………………………..……………………………… 30

2.11 Summary Tables……………………………………………………………………………………………………………….. 40
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2.11.1 Health Program Accomplishments…………………………………………………………………………… 40
2.11.2 Morbidity Diseases…………………………………………………………………………………………………… 40

2.12 Monthly Consolidated Table……………………………………………………………………………………………… 40

2.13 Summary Table for Barangays…………………………………………………………………………………………… 41
2.13.1 Maternal ‐ Pre‐Natal and Post‐Partum Care…………………………………………………………….. 42
2.13.2 Family Planning (Part 1)…………………………………………………………………………………………… 43
2.13.4 Child Care (Part 1)……………………………………………………………………………………………………. 45
2.13.5 Child Care (Part 2)……………………………………………………………………………………………………. 46
2.13.6 Child Care (Part 3)……………………………………………………………………………………………………. 47
2.13.7 Dental Health…………………………………………………………………………………………………………… 48
2.13.8 Malaria…………………………………………………………………………………………………………………….. 49
2.13.9Tuberculosis……………………………………………………………………………………………………………… 50
2.13.10 Filariasis…………………………………………………………………………………………………………………. 51
2.13.11 Leprosy………………………………………………………………………………………………………………….. 52
2.13.12 Schistosomiasis……………………………………………………………………………………………………… 53
2.13.13 Morbidity Disease Report………………………………………………………………………………………. 54
2.13.14 Blank Morbidity Disease Report ……………………………………………………………………………. 55
2.13.15 Natality (Source of Data TCL) Part 1……………………………………………………………………….. 56
2.13.16 Natality (Source of Data TCL) Part 2……………………………………………………………………….. 57
2.13.17 Natality (Source of Data LCR) Part 1………………………………………………………………………. 58
2.13.18 Natality (Source of Data LCR) Part 2………………………………………………………………………. 59
2.13.19 Environmental Health……………………………………………………………………………………………. 60
2.13.20 Mortality (Source of Data LCR or RHU logbooks)……………………………………………………. 61
2.13.21 Blank Form for Summary Table – Program…………………………………………………………….. 62

2.14 Monthly Consolidated Table for Health Centers
2.14.1 Maternal Care………………………………………………………………………………………………………….. 64
2.14.5 Child Care (Part 1)……………………………………………………………………………………………………. 72
2.14.6 Child Care (Part 2)……………………………………………………………………………………………………. 74
2.14.7 Child Care (Part 3)……………………………………………………………………………………………………. 76
2.14.8 Leprosy……………………………………………………………………………………………………………………. 78
2.14.9 Tuberculosis………………………………………………………………………………………………………… 80
2.14.10 Malaria…………………………………………………………………………………………………………………… 82
2.14.11 Filariasis…………………………………………………………………………………………………………………. 84
2.14.12 Schistosomiasis……………………………………………………………………………………………………… 86
2.14.13 Morbidity Form……………………………………………………………………………………………………… 88
2.14.14 Monthly Consolidation Form…………………………………………………………………………………. 90

2.15 The Monthly Forms for Program Report (M1)…………………………………………………………………… 92
2.15.1 Maternal Care………………………………………………………………………………………………………….. 92
2.15.2 STI Surveillance………………………………………………………………………………………………………… 93
2.15.3 Family Planning……………………………………………………………………………………………………….. 93
2.15.4 Child Care………………………………………………………………………………………………………………… 94
2.15.5 Malaria…………………………………………………………………………………………………………………….. 96
2.15.6 Tuberculosis…………………………………………………………………………………………………………….. 96
2.15.7 Schistosomiasis………………………………………………………………………………………………………… 97
2.15.8 Filariasis…………………………………………………………………………………………………………………… 98
2.15.9 Leprosy……………………………………………………………………………………………………………………. 98
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2.16 The Monthly Report of Morbidity Disease (M2)………………………………………………………………… 99

2.17 Monthly Form for Program Report (M1)…………………..………………………………………………………. 100

2.18 Morbidity Disease Report (M2)……………………………………………………………………………………….. 102

2.19 The Quarterly Forms for Program Report (Q1)………………………………………………………………….. 104
2.19.1 Maternal Care………………………………………………………………………………………………………….. 104
2.19.2 Family Planning……………………………………………………………………………………………………….. 104
2.19.3 Child Care………………………………………………………………………………………………………………… 104
2.19.4 Dental Care……………………………………………………………………………………………………………… 104
2.19.5 Tuberculosis…………………………………………………………………………………………………………….. 105
2.19.6 Leprosy……………………………………………………………………………………………………………………. 105
2.19.7 Malaria…………………………………………………………………………………………………………………….. 105
2.19.8 Schistosomiasis………………………………………………………………………………………………………… 105
2.19.9 Filariasis…………………………………………………………………………………………………………………… 105

2.20 Sample Quarterly Forms for Program Report (Q1)
2.20.1 Maternal Care………………………………………………………………………………………………………….. 106
2.20.2 Family Planning……………………………………………………………………………………………………….. 107
2.20.3 Child Care………………………………………………………………………………………………………………… 108
2.20.4 Dental Care……………………………………………………………………………………………………………… 110
2.20.5 Disease Control………………………………………………………………………………………………………… 111

2.21 Quartely Consolidation Report of Morbidity Diseases (Q2)
2.21.1 Form 1 Notifiable Diseases .……………….……………………………………………………………………. 114
2.21.2 Form 2 Other Diseases…………………………………………………………………………………………….. 115

2.22 The Annual Forms
2.22.1 Annual BHS Report (A‐BHS)……………………………………………………………………………………… 116

2.22.2 Annual Form 1 Vital Statistics Report (A1‐RHU)……………………………………………………….. 116
2.22.2.1 Demographic Information…………………………………………………………………………….. 116
2.22.2.2 Environmental………………………………………………………………………………………………. 117
2.22.2.3 Natality…………………………………………………………………………………………………………. 118
2.22.2.4 Mortality………………………………………………………………………………………………………. 119

2.22.3 Sample Annual Forms
2.22.3.1 A‐Barangay Form (A‐Brgy)…………………………………………………………………………….. 121
2.22.3.2 Demographic Profile (A1‐RHU)……………………………………………………………………… 122
2.22.3.3 Environmental………………………………………………………………………………………………. 123
2.22.3.4 Natality – Live births……………………………………………………………………………………… 124
2.22.3.5 Natality – Deliveries………………………………………………………………………………………. 125
2.22.3.6 Mortality………………………………………………………………………………………………………. 126
2.22.3.7 Morbidity Diseases Report (A2‐RHU)…………………………………………………………….. 127
2.22.3.8 Mortality Report (A3‐RHU) …………………………………………………………………………… 128

Chapter 3 - FHSIS version 2012 Metadata

3.1 Demographic Information …………………………………………………………………………………………………. 130
3.2 Natality………………………………………………………………………………………………………………………………. 135
3.3 Mortality……………………………………………………………………………………………………………………………. 139
3.4 Environmental Health………………………………………………………………………………………………………… 141
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3.5 Maternal Care……………………………………………………………………………………………………………………. 144
3.6 Family Planning………………………………………………………………………………………………………………….. 149
3.7 Child Care……………………………….………………………………………………………………………………………….. 151
3.8 Dental Health……………………………….…………………………………………………………………………………….. 160
3.9 Filariasis…….……………………………………………………………………………………………………………………….. 162
3.10 Leprosy…….………………………………………………………………………………………………………………………. 164
3.11 Malaria…….………………………………………………………………………………………………………………………. 168
3.12 Schistosomiasis………………………………………………………………………………………………………………… 171
3.13 Tuberculosis…………………………………………………………………………………………………………………….. 173
3.14 Morbidity Rates……………………………………………………………………………………………………………….. 177

Annexes

1 FHSIS Family Planning Calculation Correction on Current Users…………………………………………. 181
2.1 Management of the sick young infant age 1 week up to 2 months……..…………………………….. 185
2.2 Management of the sick child age 2 months up to 5 years…………..……………………………………. 187
2.3 Children under five years of age with Health Problems other than IMCI Classification
/Other Children / Adults…………………………………………………………………………………………………… 190
2.4 Maternal Client Record for Pre‐natal Care…………………………………………………………………………. 191
2.5 Maternal Client Record for Post‐partum and Neonatal Care………………………………………………. 194
2.6 Family Planning Service Record………………………………………………………………………………………….. 197
2.7 Dental Health Program ‐ Form 1…………………………………………………………………………………………. 199
2.8 TB Program – Individual Treatment Record………………………………………………………………………… 199
2.9 ITR for Malaria Prevention and Control Program………………………………………………………………… 203
2.10 ITR for Leprosy Prevention and Control Program………………………………………………………………. 204
2.11 ITR for Schistosomiasis Prevention and Control Program………………………………………………….. 207
2.12 ITR for Filariasis Prevention and Control Program……………………………………………………………… 208

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Acronyms

A Annual Forms
ART Altraumatic Restorative Treatment
BBT Basal Body Temperature
BEMONC Basic Emergency Obstetrics and Neonatal Care
BHS Barangay Health Stations
BHW Barangay Health Workers
BOHC Basic Oral Health Care
BTL Bilateral Tubal Ligation
CC Changing Clinic
CMM Cervical Mucus Method
CDR Case Detection Rate
CEMONC Comprehensive Emergency Obstetrics and Neonatal Care
CHO City Health Officer
CIC Completely Immunized Child
CM Changing Method
CPAB Child Protected At Birth
CPR Contraceptive Prevalence Rate
CU Current User
CVD Cardiovascular Disease
DO Drop outs
DSSM Direct Sputum Smear Microscopy
FHSIS Field Health Services Information System
FIC Fully Immunized Children
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HH Household
IMR Infant Mortality Rate
ITR Individual Treatment Record
IUD Intrauterine Device
LAM Lactational Amenorrhea Method
LB Live birth
LBW Low Birth Weight
LCR Local Civil Registry
LGU Local Government Units
LHB Local Health Board
LHW Local Health Workers
LLIN Long‐lasting Insecticide Nets
M Monthly Forms
MCT Monthly Consolidation Table
MCV Measles‐containing Vaccine
MDA Mass Drug Administration
MDG Millennium Development Goal
MFD Microfilaria Density
MHO Municipal Health Officer
MMR Maternal Mortality Ratio
MNP Micronutrient Powder
NA New Acceptors
NBS Newborn Screening
NCDPC National Center for Disease Prevention and Control
NEC National Epidemiology Center
NHTS National Household Targeting System
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ORS Oral Rehydration Salt
ORT Oral Rehydration Therapy
OUT Oral Urgent Treatment
PHN Public Health Nurse
PN Prenatal
PP Post‐partum
Q Quarterly Forms
RHM Rural Health Midwife
RDT Rapid Diagnostic Test
RHU Rural Health Units
RPR Rapid Plasma Reagin
RS Re‐starter
SDM Standard Days Method
SSESS STI Sentinel Etiologic Surveillance System
ST Summary Table
STM Symptothermal Method
SY Syphilis
TCL Target Client List
TP Total Population
TPHA TreponemaPallidumHemaglutination Assay
TT Tetanus Toxoid
WHO World Health Organization
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Chapter One
___________________
INTRODUCTION
FHSIS – DIC – 2012‐01
1.1 Introduction
The Field Health Services Information System (FHSIS) provides the Department of Health
(DOH) with management information on the different public health programs. It is the official
system of the DOH and designated national health statistics as per Executive Order 352.
Field Health Services Information System (FHSIS) was conceptualized in 1987 as a response
to the need for streamlining an existing reporting system that, midwives complained, was
burdensome, time-consuming, and ultimately even prevented them from discharging their service
delivery functions fully. FHSIS was then implemented nationwide by 1989 in a joint effort with many
sectors within and outside the Department of Health (DOH). The FHSIS is a facility-based system,
and data generated by the system comes from the Barangay Health Stations (BHS) and Rural
Health Units (RHU). This means that, data from private or non-government units, clinics, and
institutions rendering the same services as the BHS and RHU are missed.
In 1991, barely a year after the full implementation of FHSIS, the Local Government Code
(LGC) was implemented. With this decentralization, the management and provision of health
services was transferred to the Local Government Units (LGU). In order to make the FHSIS adapt
to the changes brought about by the LGC, the FHSIS technical staff formed study teams and
undertook activities aimed at improving, simplifying, and making the system more responsive and
relevant to devolution. The team focused on simplifying and shortening Summary Tables (ST) and
reducing over-dependence on computers in the production of STs. These changes constituted the
Modified FHSIS (MFHSIS) which was implemented nationwide in 1996. However, despite the
innovations, the system continued to experience problems in its operations including poor
utilization of data for decision making by leaders in various levels of the health system, and the
sub-optimal quality of the data characterized by delayed submissions and incomplete reports.
In 2001, another revision, the Decentralized FHSIS (DFHSIS), was piloted in six areas
nationwide (three provinces and three cities) in an effort to address the shortcomings of the
MFHSIS. However, this was not implemented nationwide and was not sustained due to a very
limited information generation. An evaluation of DFHSIS was undertaken in 2004 for which findings
showed the same problems of inaccuracy, incompleteness and delay from the original FHSIS and
MFHSIS. The recommendation showed DFHSIS should not be implemented nationwide unless the
support systems are enhanced (policy and implementing rules and regulations, skilled data
managers, adequate financing and efficient computerization of the system).
In 2005, The FHSIS started its program enhancement through consultative workshops.
Program managers at the national level were met to determine indicators that would suit their
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FHSIS – DIC – 2012‐01
needs. This was followed through in recent years by series of consultations with National Center
for Disease Prevention and Control (NCDPC) Program Managers and selected Rural Health Unit
Physicians, Nurses and Midwives, Provincial Health Officers to further identify information needs
and indicators in all health management systems. FHSIS ver 2008 was developed as a result of
these meetings with Program Managers and Local Government Units (LGU). This version included
the updating of indicators needed at the national level and the FHSIS software developed by the
National Epidemiology Center (NEC).
1.2 Objectives of FHSIS ver. 2012

To update indicators based on the current needs of the health program managers and all
local government units.
1.3 Principles of FHSIS ver. 2012

Indicators needed by program managers and local government units are collected in
consultative manner. Updated FHSIS metadata are featured. FHSIS ver. 2012 shall be implemented
by 2013 with the updated indicators reports published in 2014.
1.4 Components of FHSIS ver. 2012

a. Recording Tools
Facility-based documents with more detailed data and contains day to day activities of
the health workers.
 Individual Treatment Record (ITR)
 Target Client List (TCL)
 Summary Table (ST)
 Monthly Consolidation Table (MCT)
b. Reporting Tools
These are summary data that are transmitted or submitted on a weekly, monthly,
quarterly and on annual basis to the next higher level).
 Monthly Forms (M)
 Quarterly Forms (Q)
 Annual Forms (A-BHS, A1, A2, A3)
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Chapter Two
___________________
COMPONENTS OF FHSIS
FHSIS – DIC – 2012‐01
2.1 RECORDING TOOLS:
These are facility based documents. Data are more detailed and contains day to day
activities of the health workers. The source of data for this component is the services delivered
to patients/clients.
2.1.1 Individual Treatment Record (ITR)
The Individual Treatment Record is a document, form or piece of paper upon which is
recorded the date, name, address of patient, presenting symptoms or complaint of the
patient on consultation and the diagnosis (if available), treatment and date of treatment. This
record will be maintained as part of the system of records at each health facility on all
patients seen. This record may be as simple as the following example prepared on plain
bond paper:
Sample of ITR:
DELA CRUZ, ROSE M.
2106 Rizal Avenue, Siniloan, Laguna

Age: 32 years Birthday: February 7, 1980
Religion: Catholic Weight: 52 kg
Occupation: Housekeeper
4/15/2012
Complaint: Headache & vomiting
Vital signs: BP = 120/80 mmHG
Diagnosis:
Treatment/Recommendations:
NOTE: Do not rely on records maintained by the client/patient. In areas where the
home based maternal record is in use, there must still be a treatment record available in
the facility.
2.1.2 Target Client List (TCL)
The Target Client Lists constitute the second recording tool of the FHSIS and are
intended to serve several purposes. The tool enables the midwife or nurse to plan and
carries out patient care and service delivery. Such lists will be of considerable value to
midwives/nurses in monitoring service delivery to groups of patients identified as “targets” or
“eligibles” for a particular health program. TCL also facilitate the monitoring and supervision
of service delivery activities, report services delivered. TCL data may provide a clinic-level
database which can be accessed for further studies.
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FHSIS – DIC – 2012‐01
The Target Client Lists to be maintained in the FHSIS version 2012 are as follows:
Target Client List for Prenatal Care
Target Client List for Post-Partum Care
Target Client List for Nutrition and Expanded Program for Immunization
Target Client List for Family Planning
Target Client List for Sick Children
Registry Forms for Filariasis, Leprosy, Malaria, Schistosomiasis and Tuberculosis shall
be the source for all Disease Control Indicators instead of a separate TCL.
2.1.3 Summary Table
The Summary Tables is a form with 12-month columns retained at the facility (BHS)
where the midwife records all monthly data. The Summary Table is composed of; a) Health
Program Accomplishment; b) Morbidity Diseases.
a. Health Program Accomplishment – the midwife records a summary of all the data
from TCL or registries. This summary table is an easy source of data for
reports being prepared by the midwife. It would be wise to keep this updated
as this can serve as proof of accomplishments to show LGU officials
whenever they visit the facility. This also serves as the data source for any
survey, special study, or research that may include the facility. This can serve
as a tool for the midwife to assess her own accomplishments.
b. Morbidity Diseases – the midwife accomplished this table on a monthly basis. This
summary table can also be the source of ten leading causes of morbidity and
reportable disease for the municipality/city. This summary table will help the Health
Centers staff get the monthly trend of diseases.
2.1.4 Monthly Consolidation Table (MCT)
The Monthly Consolidation Table - the Public Health Nurse (PHN) records data from all
barangays. This is the source document of the nurse for the Quarterly Form. The MCT shall
serve as the output table of the RHU as it already contains listing of indicators by barangay.
2.2 REPORTING TOOLS:
These are summary data that are transmitted or submitted on a monthly, quarterly and
on annual basis to higher level. The source of data for this component is dependent on the ST
and MCT.
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FHSIS – DIC – 2012‐01
2.2.1 The Monthly Form
2.2.1.1 Program Report (M1)
The Monthly Form contains selected indicators categorized as maternal care, child
care, family planning and disease control. The indicators found in the TCL and Summary
Tables are also recorded in M1. The midwife should copy the data from the Summary
Table to the Monthly Form which she regularly submits monthly to the public health nurse.
It helps the midwife capture the monthly data so that it would be easier for the nurse to
consolidate and prepare the quarterly report.
2.2.1.2 Morbidity Report (M2)
The Monthly Morbidity Disease Report contains a list of all diseases by age and
sex. The midwife uses the form for the monthly consolidation report of Morbidity Diseases
and is submitted to the PHN for quarterly consolidation.
2.2.2 The Quarterly Form
2.2.2.1 Program Report (Q1)
The Quarterly Form is the municipality/city health report that contains the three-
month total of indicators categorized as maternal care, family planning, child care, dental
health and disease control. There should only be one Quarterly Form per municipality/city.
In the event that there are two or more RHUs/MHCs in the municipality/city, the
consolidation shall be done by or under the direction of the MHO/CHO who sits as
vice chairperson of the Local Health Board (LHB). The Quarterly Form is submitted to
the Provincial Health Office (PHO) for consolidation.
2.2.2.2 Morbidity Report (Q2)
The PHN uses the form for the Quarterly Consolidation Report of Morbidity
Diseases to consolidate the Monthly Morbidity Diseases taken from the Summary Table.
The Quarterly Consolidation Report of Morbidity Diseases is submitted every third week of
the first month of the succeeding quarter.
2.2.3 The Annual Forms (A-BRGY, A1, A2 & A3)
The Annual Form 1 (A1) consists of data and indicators needed only on a yearly
basis. A-BRGY Form is the report of midwife which contains data on demographic,
environmental, natality and mortality. Annual Form 2 (A2) is the report, listing all
diseases and their occurrence in the municipality/city. This report is disaggregated by
age and sex. Annual Form 3 (A3) is the report of all deaths occurred in the
municipality/city disaggregated by age and sex.
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FHSIS – DIC – 2012‐01
2.3 RECORDING AND REPORTING TOOLS GUIDE
Locus of Recording Reporting Tools Frequency Schedule of Submission

Responsibility Tools
to higher level
Office Person
ITR Monthly Forms Monthly every second week of succeeding

BHS Midwife TCL (M1 & M2) month
ST A-BRGY Form Annually every second week of January
Quarterly Forms Quarterly every third week of the first month

(Q1 & Q2) of the succeeding quarter
ITR Annual Forms
TCL > A1
ST > A2
RHU PHN MCT > A3 Annually every third week of January
Quarterly Reports Quarterly every fourth week of the first

PHO/ Prov./City (Q1 & Q2) month of the succeeding quarter
CHO FHSIS Annual Reports Annually every fourth week of January
Coordinator > A1
> A2
> A3
- Quarterly Report Quarterly every second week of the second
CHD Regional month of the succeeding quarter
FHSIS - Annual Reports Annually every second week of March
Coordinator > A1
> A2
> A3
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FHSIS – DIC – 2012‐01
2.4 REPORTING FLOW:
9
FHSIS – DIC – 2012‐01
TARGET CLIENT LIST:
2.5 Target Client List for Prenatal Care
The target client list for prenatal care will include all pregnant women eligible for pre-
natal care/service. The individual patient record or pre-natal record must still be maintained
together with this list to record information of importance to the patient which otherwise is not
included in the client list (e.g. the FHB, Wt., BP) for every pre-natal visit.
The target client list must be properly filled-up and updated as soon as possible following
a patient’s visit by the midwife in the BHS and the nurse/midwife in the RHU. The trained BHW
can also be given the responsibility of recording provided they are under the direct supervision of
the nurse or midwife.
Column 1 – DATE OF REGISTRATION – Write in this column the month, day and year a pregnant
woman was first seen at the clinic for pre-natal visit.
Column 2 – FAMILY SERIAL NUMBER – Enter in this column the number that corresponds to the
number of the family folder or envelope or individual treatment record. This column
will help you facilitate retrieval of client’s record.
Column 3 - NAME – Write the given name, middle initial and family name of the woman.
Column 4 – ADDRESS – Write the complete address: number of the house, name of the street,
barangay, municipality and province. This column will help you to monitor or
follow-up the client.
Column 5 – AGE – Write the age of the woman at her last birthday. .
Column 6 – LAST NORMAL MENSTRUAL PERIOD /GRAVIDA-PARITY

LMP/GP - Write in this column 2 entries. First is the date of the last menstrual
period (month, first day of LMP and the year) followed by gravida-parity (G-P) of
the client. LMP is important because this is the basis for computing the EDC of the
mother while GP is important to know if pregnancy is of risk.
Example:
LMP/G-P
(5) (6) (7)
4-14-12/
4-3
This means that the last menstrual period of the woman was 4-14-12 and she had
4 pregnancies (gravida) including the current pregnancy and 3 deliveries (parity).
Column 7 – EDC or EXPECTED DATE OF CONFINEMENT – Write in this column the expected
date of delivery. This column is important for follow-up visits to prevent post maturity.
Formula for Computing EDC:

LMP: January-March = + 9 mos. +7 days + 0
April-December = - 3 mos. +7 days + 1 year
Example: LMP = 4 14 2012

Formula = - 3 + 7 + 1
EDC = 1 21 2013
10
FHSIS – DIC – 2012‐01
Column 8 – PRENATAL VISIT (DATES) – This has 3 sub-columns representing the trimester of
pregnancy. All dates of pre-natal visits either clinic or home of a particular
pregnant woman must be entered in this column corresponding to the trimester of
pregnancy when the visit was undertaken. If a pregnant woman comes in the clinic
in the first 3 months of her pregnancy (i.e. first trimester) enter the date of that
check-up under column 8, 1st trimester. Dates of all succeeding visits should be
indicated in the appropriate trimester column. It is possible that more than one
date appears in each column. Also, visits from other DOH facilities, private
hospital/clinic should also be recorded in this column as long as there is a way to
validate that the visit is a PNV. This column is important for early detection of risk
pregnancies thus protecting both the mother and the baby.
Trimesters of Pregnancy:
The First Trimester = up to 12 weeks or 0-84 days
The Second Trimester = 13-27 weeks or 85-189 days
The Third Trimester = 28 weeks and more or 190 days and more
Column 9 – TETANUS STATUS – Write in this column the tetanus toxoid immunization already
received by the pregnant woman (either from the past pregnancy or present
pregnancy) when she made her first visit to the facility. The record of past
pregnancies can be used to obtain this information. Use the following codes:
Code
TT1 The woman has received only one dose of tetanus
toxoid during this pregnancy from other DOH facility
(e.g. transferred residence)
TT1 & TT2 The woman has received 2 doses of tetanus toxoid during
this pregnancy from other DOH facility (e.g.
transferred residence) and any woman who has
received TT1 and TT2 during the past pregnancy.
TT3 The woman has received TT1 and TT2 together with TT3
TT4 The woman has received TT1, TT2, TT3 and TT4
TT5 The woman has received TT1, TT2, TT3, TT4 and TT5
TTL Presently pregnant woman who already received
the 5 doses tetanus toxoid (Fully Immunized Mother)
NONE Women without previous history/record of
tetanus immunization or women having her pre-natal
visit for her first pregnancy
UNKNOWN If no information can be obtained from the records or
history of the woman.
Column 10 - TETANUS TOXOID VACCINATION GIVEN – Write in this column

the date each tetanus toxoid is given during the course of the
present/current pregnancy.
11
FHSIS – DIC – 2012‐01
Tetanus Toxoid (TT) Immunization Schedule
TT Dose Interval
As early as possible during first pregnancy or even in
TT1
a non-pregnant child bearing age woman
TT2 4 weeks after first dose within the same pregnancy
TT3 6 months after TT2

TT4 1 year after TT3
TT5 1 year after TT4
Column 11 – MICRONUTRIENT SUPPLEMENTATION – Write the date and number Iron with
Folic Acid was given
Column 12 – STI SURVEILLANCE – This has 3 sub columns. For TESTED FOR SYPHILIS
column, write the date the test was done; for RESULT FOR SY TESTING, put “+”
if RPR or RDT result is Positive and put “-” if RPR or RDT result is Negative. The
date the test was done is also recorded. For GIVEN PENICILLIN column, put “Y if
positive for Syphilis pregnant women was given Penicillin and put “N” if not.
Column 13 – PREGNANCY – Write the date (month, day and year) when the current pregnancy
was terminated in the sub-column DATE TERMINATED and in the OUTCOME
sub-column, write the outcome of the pregnancy whether it is a live birth, fetal
death or abortion and the sex. It is possible that two codes appear in this sub-
column. Use the following codes:
Code Definition
LB Live birth - the complete expulsion or extraction from the mother’s
womb of a product of conception, irrespective after such
separation, breathes or shows any other evidence of life such
as beating of the heart, pulsation of the umbilical cord or
definite movement of muscles.
FD Fetal Death - death of the fetus prior to the complete
expulsion from the mother; the death is indicated by the
fact that after separation, the fetus does not breath or
show any evidence of life such as beating of the heart,
pulsation of the umbilical cord or definite movement of
voluntary muscles. (20 weeks and above)
AB Abortion–termination of pregnancy before the fetus becomes
viable. (before the 20th week or 5 months of pregnancy)
Column 14 – LIVE BIRTHS – In case of Live birth, the weight of the infant in grams must appear
in the BIRTH WEIGHT sub-column. If there is more than one birth, all birth weights
in grams must appear. In the PLACE OF DELIVERY sub-column, write “health
facility if delivery occurred in RHU, BeMONC, CeMONC, Hospital and lying-in
clinics; write “Non-Institutional Delivery if delivery occurred otherwise (home, taxis,
etc). It is possible that two entries appear in this sub-column in case of multiple
births at different places. In the ATTENDED sub-column, write the corresponding
code of the person’s designation with the highest professional rank.
12
FHSIS – DIC – 2012‐01
Code Designation
MD Doctor
RN Nurse
RM Midwife
H Hilot/TBA
O Others
Column 15 – REMARKS – Make a note under this column why a pregnant woman failed to return
for the next prenatal care. Indicate dates and reasons such as transferred to
another province, presently ill, hospitalized, etc. Also include other data of
importance to the patient.
13
NAME OF BARANGAY/RHU:
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL-PN TARGET CLIENT LIST FOR PRENATAL CARE

DATE OF FAMILY D A T E
REGIS- SERIAL LMP EDC PRENATAL VISITS
NAME ADDRESS AGE
TRATION NO. mm/dd/yy (mm/dd/yy) (8)
mm/dd/yy G-P FIRST SECOND THIRD

(1) (2) (3) (4) (5) (6) (7) TRIMESTER TRIMESTER TRIMESTER
NOTE: First Trimester = the first 3 months (up to 12 weeks or 0-84 days)
Second Trimester = the middle 3 months (13-27 weeks or 85-189 days)
Third Trimester = the last 3 months (28 weeks and more or 190 days and more)
15
TARGET CLIENT LIST FOR PRENATAL CARE
DATE TETANUS TOXOID VACCINE MICRONUTRIENT SUPPLEMENTATION STI SURVEILLANCE PREGNANCY LIVEBIRTHS
TETANUS GIVEN (11) (12) (13) (14)
REMARKS
STATUS (10) DATE & NUMBER TESTED RESULT FOR GIVEN OUT- BIRTH PLACE OF
DATE
(9) IRON W/ FOLIC ACID FOR SY SY TESTING PENICILLIN COME*/G WEIGHT ATTENDED
TERMI- Health
ender NID BY***
TT1 TT2 TT3 TT4 TT5 WAS GIVEN DATE (+/-) / DATE Y/N NATED (grams) Facility**
(M/F) (15)
*Outcome: **Health Code: ***Attended by:

LB = Livebirth Facility or RHU MD = Doctor
FD = Fetal Death Non- BeMONC RN = Nurse
AB = Abortion Institutiona CeMONC RM= Midwife
Delivery Hospital H = Hilot/TBA
(NID) Lying-in clinics O = Others
This refers to deliveries by place:
Health facility: Hospitals, RHUs, lying-ins/birthing homes (including BEMOC, CEMOC)
Non-institutional delivery (NID) includes: home, in-transit and others.
16
FHSIS – DIC – 2012‐01
2.6 Target Client List for Post-Partum Care
The Target Client List for Post-Partum Care will include all the women within the
catchment area who had a delivery. This list should be considered as an extension of the
TARGET CLIENT LIST FOR PRE-NATAL CARE. The names of women are entered upon
termination of pregnancy or women, whose terminations of pregnancy were not attended by the
midwife or nurse, their names are also entered in the list upon knowledge of a birth in the
catchment area, visit to facility or a home visit.
The list must be properly updated and exact dates indicated in each column by
responsible personnel i.e. the midwife in the BHS, the nurse or the midwife in the RHU or the
trained BHW under the direct supervision of the nurse or midwife.
Column 1 DATE AND TIME OF DELIVERY – Write in this column the month, day, year and time
of termination of pregnancy of the mother.
Column 2 FAMILY SERIAL NUMBER – Enter in this column the number that corresponds to the
number of the family folder or envelope or individual treatment record. This column will
help facilitate retrieval of client’s record.
Column 3 NAME – Write the given name, middle initial and family name of the woman.
Column 4 ADDRESS – Write the complete address: number of the house, name of the street,
barangay, municipality and province. This column will help you to monitor or follow-up
the client.
Column 5 DATE OF POSTPARTUM VISITS – This column is divided into two sub-columns. Write
the date of postpartum visits at home or at the clinic within 24 hours upon delivery and
within one week after delivery.
Column 6 DATE AND TIME INITIATED BREASTFEEDING – write the date and the time post-
partum mother initiated breastfeeding.
Column 7 DATE SUPPLEMENTATION WAS GIVEN – This column is divided into iron and
vitamin supplementation. For iron supplementation column, write the date/s and number
of tablet given to post-partum women. For Vitamin A, write only the date
supplementation was given.
Column 8 REMARKS – Under remarks column enter information which you feel important for post-
partum care mothers.
17
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL-PP CLIENT LIST FOR POSTPARTUM CARE

DATE & FAMILY DATE POST-PARTUM VISITS DATE AND MICRONUTRIENT SUPPLEMENTATION REMARKS
TIME OF SERIAL NAME ADDRESS (5) TIME (7) (8)
DELIVERY NO. W/IN 24 HOURS WITHIN ONE INITIATED IRON VITAMIN A
AFTER WEEK AFTER BREASTFEEDING DATE / NO. TABLETS DATE
(1) (2) (3) (4) DELIVERY DELIVERY (6)
19
FHSIS – DIC – 2012‐01
2.7 Target Client List for Family Planning
The Target Client List for Family Planning will include all eligible women aged 15-49 and
men who are receiving a family planning service provided by the reporting clinic. The Family
Planning Service provided by the reporting clinic will include Condom, injectables (DMPA/CIC),
Intra-Uterine Device (IUD), NFP-Lactational Amenorrhea Method (NFP-LAM), NFP-Basal Body
Temperature (NFP-BBT), NFP-Cervical Mucus Method (NFP-CM), NFP-Sympothermal Method
(NFP-STM), NFP-Standard Days Method (NFP-SDM), Pills, Implants, Female Sterilization/Bilateral
Tubal Ligation (FSTR/BTL) and Male Sterilization/Vasectomy.
The Target Client List should be by Family Planning Method and be updated immediately
after a client visits the facility.
Column 1 – DATE OF REGISTRATION – Indicate in this column the date (month, day and year)
an eligible person made the first clinic visit or the date when client fail to comeback after a
year, the client has to be registered again.
Column 2 - FAMILY SERIAL NUMBER – Indicate in this column the number that corresponds to
the number of the family folder or envelope or individual treatment record. This column will
help you facilitate retrieval of client’s record.
Column 3 – NAME – Write the given name, middle initial and family name of the client.
Column 4 – ADDRESS – Write the complete address: number of the house, name of the street,
barangay, municipality and province. This column will help you monitor or follow-up the
client.
Column 5 – AGE/BIRTHDATE – Indicate in this column the age of the client as of last birthday and
below indicate the birthdate.
Column 6 – TYPE OF CLIENT – Indicate in this column any of the applicable categories:
Code Type of Client

NA New Acceptors – a client who has NEVER accepted
any FP method at any clinic before
CU Current Users – current users carried over from last
month client list. Includes:
 Changing Method (CM) – a continuing user who is shifting

to another Method
 Changing Clinic – a continuing user using the same

method, however the client is new to the clinic
 Restart – a client who have stopped FP practice for at least

1 month and have resumed using the same method in the
same clinic.
NOTE: For clients who are changing methods/changing clinic, they should be
recorded as a DROP-OUT from their previous method and indicate the reason
as ‘CHANGING METHOD/Changing Clinic”. The client is still categorized as
current users.
20
FHSIS – DIC – 2012‐01
Column 7 – PREVIOUS METHOD – refers to the last method used prior to accepting the new
method. Using the following codes, add code for NONE to cover “New to Program”.
Codes Methods
PILLS Pills
FSTR/BTL Female Sterilization/Bilateral Tubal Ligation
INJ Depo-medroxy Progestone Acetate(DMPA)/ Combined
Injectables Contraceptives(CIC)
IUD Intra-Uterine Device (including Post-partum-IUD & Interval IUD)
NFP-BBT Natural Family Planning-Basal Body Temperature
NFP-CM Natural Family Planning-Cervical Mucus Method
NFP-STM Natural Family Planning-Symptothermal Method
SDM Natural Family Planning-Standard Days Method
LAM Lactational Amenorrhea Method
MSTR/VASECTOMY Male Sterilization/Vasectomy
CON Condom
Implants Implants
Column 8 – FOLLOW-UP VISITS – Write in this column 2 entries; in the upper space is the
scheduled date of visit and at the lower space is the actual date of visit. A client who is
scheduled for a particular month and failed to make the clinic visit will only have one date
entered in that particular month.
Column 9 – DROP-OUT – write the date client has been dropped from the TCL based on the
following method.
The following are the definitions for each method drop-out:
a. Pill - A client is considered drop-out from the method if she:
i fails to come and get her re-supply from the last 21 white
pills up to the last brown pill (if the pills have a set of brown tablets/Iron);
or within 7 days from the 21st pill / last pill (if the pills contain only a set
of white tablets)
ii gets supply or transfers to another provider or clinic: in this case, the

client is listed under the other acceptor (“changed clinic”) in the clinic
where she transferred and a drop out in her former clinic.
iii decided to stop the use of pills for any reason
Note: The service provider should undertake follow-up visits of the client
within this period before dropping her from the method.
b. Injectables – A client is considered drop-out if she:
i fails to have a follow-up visit on the last day of 2 weeks before or after
the scheduled date of visit for DMPA; fails to have a follow-up visit on
the last day of 1 week before or after scheduled date of visit.
ii gets supply or transfers to another provider; the client is under the Other
Acceptor (“Changed Clinic”) in the clinic where she transferred and
considered a drop-out in her former clinic
iii stops receiving injection for any reason
21
FHSIS – DIC – 2012‐01
Note: the service provider should undertake a follow-up visit during the above
period prior to dropping her out of the method.
c. IUD – client is considered drop-out if:
i client decided to have it removed
ii had expelled IUD that was not re-inserted and
iii client did not return on the scheduled date of follow-up visits 3-6 weeks
after insertion from when the procedure was done. It is best medical
practice to follow-up on the client yearly, but the client is dropped out if
she does not return for two years.
d. Condom – client is considered drop-out if she/he fails to return for re-supply on

scheduled visit; or decides not to use condom for any reason
e. LAM – client is considered drop-out if any one of the three (3)

conditions is not met as follows:
i Mother has no menstruation or amenorrheic within six months. Spotting

or bleeding during the last fifty-six (56) days postpartum is not
considered return of menses.
ii Fully/exclusive breastfeeding means no other liquid or solid except

breast milk be given to the infant, intervals should not exceed four hours
during the day and six hours at night.
iii Baby is less than six (6) months old
f. NFP
for Standard Days Method – A client is considered a drop-out if she fails to

return on the follow-up date to identify her own fertile and infertile periods, has
no indication SDM use through beads or no knowledge of first day of
menstruation or cycle length, or decides to stop the use of the method. The
service provider should undertake a follow-up visit during the above period prior
to dropping her out.
for BBT / Billing’s / Symptothermal Method – A client is considered a drop-out if

client fails to return on the follow-up date to check on the correct charting and/or
the proper use of the method, fails to identify her own fertile and infertile periods,
decides to stop the use of the method.
Note:
 Client is given a period of time (2 months) as a learning user to practice
correct charting with assistance before recording the client as a new
acceptor. A new acceptor is considered if the client can identify and
chart her fertile and infertile period correctly.
 An autonomous user can be considered a Current User as these clients

no longer need assistance in charting from the health workers.
22
FHSIS – DIC – 2012‐01
 The service provider should undertake a follow-up visit during the above
period prior to dropping her out.
g. Female Sterilization/ BTL - client is considered drop-out if she reaches the age beyond 49
years or experiences the following conditions: menopausal, underwent hysterectomy
or bilateral salpingo-oophorectomy.
NOTE: Follow up of clients should be undertaken prior to the dropping out of the client
from the method.
h. For Implants – a client is considered a drop-out if she did not return to the facility 3 years
after the implant insertion for removal and replacement of the implant rod.
Column 10 – REMARKS – Indicate in this column the date and reason for every referral MADE to
other clinic and referral RECEIVED from other clinic which can be due to medical
complications or unavailable family planning services and other pertinent findings significant
to client care.
23
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL-FP
TARGET CLIENT LIST FOR FAMILY PLANNING - ___________________
(PUT NAME OF FP METHOD)
TYPE OF PREVIOUS
DATE OF REGISTRATION FAMILY SERIAL AGE
NAME ADDRESS CLIENT* METHOD**
NO. Birthdate
mm/dd/yy (use codes) (use codes)

(1) (2) (3) (4) (5) (6) (7)
* Type of Client: CU = Current Users ** Previous Method:

NA = New Acceptors CON = Condom NFP-BBT = Basal Body Temperature SDM = Standard Days Method
INJ = DMPA or CIC NFP-CM = Cervical Mucus Method MSTR/Vasec = Male Ster./Vasectomy
Other Acceptors: IUD = Intra-uterine Device (PP-IUD and I-IUD) NFP-STM = Sympothermal Method FSTR/BTL = Female Ster./Bilateral
* CU-CM = Changing Method PILLS = Pills NFP-LAM = Lactational Amenorrhea Method tubal ligation
* CU-CC = Changing Clinic IMP=Single rod sub-thermal Implant
* CU-RS = Restarter NONE or New Acceptor
25
TARGET CLIENT LIST FOR FAMILY PLANNING
FOLLOW-UP VISITS
(Upper Space: Next Service Date / Lower Space: Date Accomplished) DROP-OUT
REMARKS/
ACTION
(8) (9) TAKEN
1ST 2ND 3RD 4TH 5TH 6TH 7TH 8TH 9TH 10TH 11TH 12TH DATE Reason*** (10)
*** ReasoA = Pregnant F = Husband disapproves K = Change Method For LAM:

B = Desire to become G = Menopause L = Underwent Hysterectomy A - Mother has a menstruation or not amenorrheic within 6 mos. or
pregnant H = Lost or moved out of the M= Underwent Bilateral B - No longer practicing fully/exclusively breastfeeding or
C = Medical complications or residence Salpingo-oophorectom C - Baby is more than six (6) months old
D = Fear of side effects I = Failed to get supply N = No FP Commodity
E = Changed Clinic J = IUD expelled O = Unknown
P = Age out for BTL
26
FHSIS – DIC – 2012‐01
2.8 Target Client List for Nutrition and Expanded Program for Immunization Part I
The Target Client List for Nutrition and Expanded Program for Immunization should include all children under
one year old eligible for immunization against the most common vaccine-preventable disease that results to
permanent disability or death among infants and the under-five children, iron supplementation, newborn
screening and breastfeeding. An entry should be made on this list when a delivery is made by pregnant
women on the TCL-PN. Also, include list of eligible newborns and infants from the local birth registration
office and from births that occurred within the community including transferees to have a complete list of
expected number of children.
The updated recording of this list is the responsibility of the midwife in the BHS and the nurse/midwife in the
RHU. A trained BHW or volunteer can also be given the responsibility of recording provided they are under
the supervision of the nurse/midwife.
Column 1 DATE OF REGISTRATION – Write in this column the month, day and year an infant was
seen at the clinic or at home for health services.
Column 2 DATE OF BIRTH – Write in this column the month, day and year of birth. This column is
important for immunization schedule.
Column 3 FAMILY SERIAL NUMBER – Indicate in this column the number that corresponds to the
number of the family folder or envelope or individual treatment record. This column will help
you facilitate retrieval of the client’s record.
Column 4 NHTS – Write the symbol (*) to indicate that the infant is from the NHTS list provided by the
DSWD
Column 5 NAME OF CHILD – Write the complete name of the child.
Column 6 WEIGHT – Write the weight of the child in kilograms.
Column 7 LENGHT/HEIGHT – Write the length of children under 2 years, and write the height of
children 2 years and over in centimeters.
Column 8 SEX – Write the sex of infant; “M” for male and “F” for female.
Column 9 COMPLETE NAME OF MOTHER – Write in this column the name of the mother (Family
Name, First Name, and Middle Initial)
Column 10 COMPLETE ADDRESS – Record the client’s permanent place of residence. This column
will help you to monitor or follow-up the client.
Column 11 DATE OF NEWBORN SCREENING – This is divided into two sub-columns. The first sub-
column refers to those given with referral only and on the second sub-column refers to
newborn screening done in the health center. Write the date only.
Column 12 CHILD PROTECTED AT BIRTH (CPAB) – Write the Tetanus Toxoid Status of the mother in
the sub-column TT STATUS - TT1, TT2, TT3, TT4, TT5 or Fully immunized mother (FIM)
and if the mother received TT2 only, write the month and year TT2 was given. Write the
month and year the child was classified as CPAB.
Column 13 DATE IMMUNIZATION RECEIVED – Indicate in these columns the exact date the child
received each antigen or vaccine.
27
FHSIS – DIC – 2012‐01
Routine Immunization Schedule for Infants
Vaccine Age No. of Reason

Doses
BCG Birth or any time after birth 1 BCG is given at the earliest
possible age protects against
the possibility of infection
from other family member
HepaB Birth Dose Birth (w/in 24 hrs.) 1 Reduces the chance of being
infected and becoming a
carrier of Hepatitis B infection
PENTAVALENT-1 1 6 weeks 3 An early start with Pentavalent vaccine
(DTaP+HepB +HiB) reduces the chance of
PENTAVALENT-2 1 10 weeks severe pertussis, diphtheria,
(DTaP+HepB +HiB) tetanus, Hepa B and H Influenza
PENTAVALENT-3 1 14 weeks Type B (HIB)
(DTaP+HepB +HiB)
OPV1 6 weeks 3 The extent of protection

OPV2 10 weeks against polio is increased
OPV3 14 weeks the earlier the OPV is given
Measles 9 months 1 At least 85% of measles can
be prevented by
immunization at this age
MMR 12 months 1 Provide additional protection from
Measles, mumps and German
measles
ROTA1 6-32 weeks (1 mos. apart 2 Prevents severe diarrhea caused by
ROTA2 from the last dose) rotavirus
Note: HepaB Birth Dose – Write the date and time Hepa B vaccination was given
Rotavirus Vaccine – Write the date vaccination was given. In case the child is under immunized or
missed a dose, write “not given”
Column 14 DATE FULLY IMMUNIZED – Write the exact date the child was given the last dose of the
scheduled immunization which makes the child a fully immunized child.
Note: A Fully Immunized Child (FIC) is a child that has received all of the following:
a. One dose of BCG at birth or any time before reaching 12 months
b. 3 doses each OPV, 3 doses each of Pentavalent vaccines and
c. One dose of anti-measles vaccine before reaching 12 months
Note: If the infant was given the vaccine in other health facilities, ask for the immunization card and write
the date and name of the facility the infant was given the specific dose of the vaccine.
Column 15 CHILD WAS EXCLUSIVELY BREASTFED – This column is divided into 6 sub-columns. For
sub-columns “1st to 5th month”, put a check if the child was exclusively breastfed while for
sub-column “6th month”, write the date if the child was exclusively breastfed.
Column 16 COMPLEMENTARY FEEDING – This column is divided into 3 sub-columns. Place a check
if the child was given complementary food at 6th , 7th and 8th month.
28
FHSIS – DIC – 2012‐01
Column 17 REMARKS – Write the reasons why a child failed to return for the
next immunization schedule or why a child reaching 1 year of age was not fully immunized,
to include illnesses, hospitalization, and other data of importance to the child.
2.9 Target Client List for Nutrition and Expanded Program for Immunization Part II
Column 1 DATE OF REGISTRATION – Write in this column the month, day and year an infant was
seen at the clinic or at home for health services.
Column 2 DATE OF BIRTH – Write in this column the month, day and year of birth. This column is
important for immunization schedule.
Column 5 WEIGHT – Write the weight of the child in kilograms.
Column 6 LENGHT/HEIGHT – Write the length of children under 2 years, and write the height of
children 2 years and over in centimeters.
Column 7 SEX – Write the sex of infant; M for male and F for female.
Column 8 COMPLETE NAME OF MOTHER – Write in this column the name of the mother (Family
Name, First Name, Middle Initial)
will help you monitor or follow-up the client.
Column 10 MICRONUTRIENT SUPPLEMENTATION– This column consists of 3 sub-columns. For

Vitamin A Supplementation column, write the age in months and the date Vitamin A was
received by the infant, and on the Iron column, write the birth weight and date iron was
received by the infant, and on the MNP column write the date MNP was received by the
infant.
Note: Vitamin A received means 1 dose of 100,000 I.U. (one capsule) is given anytime during the 6-11
months. Iron completely received means dosage is 0.3 ml once a day to start at two months of age
until 6 months when complementary foods are given. (Preparation is 15 mg. elemental iron/0.6 ml)
MNP received means 60 sachets is given anytime during 6-11 months and 120 sachets is given
anytime during 12-23 months children.
29
FHSIS – DIC – 2012‐01
Micronutrient Supplementation Schedule for Infants
Micronutrient Age No. of Dose Reason

Vitamin A Capsule 6 – 11 months 1 dose VAC is given starting 6 months to reduce
(100,000 I.U.) child mortality. It also
reduces the severity of the disease
12- 59 months 1 capsule every 6 mos.
Iron 6-11 months 15 mg. elemental iron
/0-6 ml once a day for
3 months
Micronutrient 6 – 11 months 60 sachets over a period of 60 sachets are adequate to rapidly
Powder - Vitamix 6 months improve hemoglobin concentration
and iron stores in a large proportion
=10 sachets/ months of infants.
=30 sachets/ quarter
=60 sachets/ 6 months
Column 11 DEWORMING – Put a check if the child was given de-worming tablet.
2.10 Target Client List for Sick Children
The Target Client List for Sick Children should include all children under 6 years of age (1) who are
sick with Measles, Severe Pneumonia, persistent Diarrhea, Malnutrition, Xerophthalmia, Night Blindness,
Bitot’s spots, Corneal Xerosis, Corneal Ulcerations and Keratomalacia and are eligible for Vitamin A
supplementation (2) Anemic children who are eligible for Iron; (3) Children with Diarrhea and (4) Children
with Pneumonia.
The updated recording of this list is the responsibility of the midwife in the BHS and the
nurse/midwife in the RHU. A trained BHW or volunteer can also be given the responsibility of recording
provided they are under the supervision of the nurse/midwife.
Column 1 DATE OF REGISTRATION – Indicate in this column the date (month, day and year) the
child was identified to be sick.
Column 4 DATE OF BIRTH – Write in this column the month, day and year of birth.
Column 5 SEX – Write the sex of infant. “M” for male and “F” for female.
help you monitor or follow-up the client.
Column 7 VITAMIN A –On the first sub-column, put a check in the column that corresponds to the
following age-group: 6-11 and 12-59 months. For the second sub-column, write the
corresponding code for the diagnosis/findings and on the last column write the date Vitamin
A was given. Use the following codes for diagnosis/findings:
30
FHSIS – DIC – 2012‐01
Code Diagnosis/Findings Definition

A Measles • History of fever (38C or more) or hot to
touch; and
• generalized non-vesicular rash of 3
or more days duration and
•at least one of the following: cough,
coryza or conjunctivitis
B Severe Pneumonia Presence of any general danger sign or chest
indrawing or stridor in calm child
C Persistent Diarrhea An episode of soft to watery stools lasting more
than 14 days
D Severely Underweight Children whose weight are classified as very
much lower than normal for his/her age. Has less
than 3 standard deviation.
E Xerophthalmia Used to include all signs and symptoms affecting
the eye that can be attributed to Vitamin A
deficiency. It Includes ocular manifestation of
VADlike night blindness, conjunctivalxerosis,
bitot’s spots, corneal xerosis, corneal
ulcer/keratomalacia and corneal scar.
Is a principal clinical sign of VAD. It is

characterized by changes in the conjunctiva,
which is the membrane that covers the white
area of the eye, leading to Bitot’s spots.
When the severity of VAD increases, this may be

followed by changes in the cells of the cornea,
which is the part of the eye that covers the iris
and the pupil, and will result in corneal, which is
the part of the eye that covers the iris and the
pupil; and will result in corneal ulcer and
blindness.
F Night Blindness Described as having difficulty in seeing in the
dark, gropes and bumps in furniture and other
objects along the way, asks questions at dusk
like: It is already dark? Where is the door? Some
local names for night blindness are “matang-
manok”, “kurap”, “harapon”, “halap”.
G Bitot’s spots These are foamy, soapy, whitish patches seen on

the white part of eye/ sclera conjunctiva).
Frequently associated with night blindness. It can
be removed but may re-accumulate later. These
patches are caused by the shedding of dead
epithelial cells. It may not disappear completely
after high doses of Vit. A capsule treatment
especially in older children and adults.
H Corneal Xerosis Cornea is cloudy and dry with an orange-peel
appearance. Some people call this fish scale
over the years. Child’s vision is diminished even
at daytime
I Corneal Ulcer Cornea becomes soft, bulges with large
perforation or holes in the surface. Children with
prolonged diarrhea and measles frequently
develop this stage. Cornea looks dull and has a
small crater
J Keratomalacia Cornea is soft and no longer flat. It may budge
because of its excessive softness. The cornea is
31
FHSIS – DIC – 2012‐01
in danger of rupturing.
K Corneal Scar Cornea has a whitish/ grayish discoloration. This
is due to the healed ulcer or previous VAD.
Schedule of High Dose of Vitamin A for High Risk Children
Diagnosis Preparation per Vit. A Dosage & Schedule of

capsule Administration
Measles 100,000 IU for infants Give one capsule upon diagnosis
6-11 months old regardless of when the last dose
200,000 IU for children of vitamin A capsule (VAC) was
12-59 mos. old given. Give another capsule after
24 hrs.
Severe pneumonia, 100,000 IU for infants Give one capsule upon
persistent diarrhea or 6-11 months old diagnosis, except when the child
severely underweight 200,000 IU for children was given VAC less than 4 weeks
12-59 mos. old before diagnosis
Cases with 100,000 IU for infants Give one capsule Immediately

Xerophthalmia, including 6-11 mos. old upon diagnosis. Give one
night blindness, Bitot’s 200,000 IU for children capsule the next day, and another
spots, corneal xerosis, 12-59 mos. old 1 capsule 2 weeks after.
corneal ulcerations,
and keratomalacia
COLUMN 8 ANEMIC CHILDREN GIVEN IRON SUPPLEMENTATION – On the first column, write the
age in months of the sick children followed by the date started iron and date completed.
COLUMN 9 DIARRHEA CASES – Write the age in months of the sick children followed by the dates
ORT, ORS and ORS with zinc was given.
COLUMN 10 PNEUMONIA CASES – Write the age in months of the sick children followed by the date
antibiotic treatment was given.
COLUMN 11 REMARKS – Write other data of importance to child care.
32
TARGET CLIENT LIST FOR
NUTRITION AND EXPANDED
PROGRAM FOR IMMUNIZATION
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL- 1
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART I
LENGTH/HEIGHT
DATE OF DATE FAMILY DATE CHILD PROTECTED
WEIGHT
REGISTRA- OF BIRTH SERIAL NHTS * NAME OF CHILD SEX COMPLETE NAME COMPLETE ADDRESS NEWBORN AT BIRTH (CPAB)**
TION (mm/dd/yy) NUMBER (M/F) OF MOTHER SCREENING (12)
(mm/dd/yy) (11) TT Status DATE
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) REFERRAL DONE Date ASSESS
* NHTS - to indicate that the infant belongs ** Child Protected at Brefers to a child whose (1) Mother has received 2 doses of TT during this
to the CCT/NHTS families listed by pregnancy, provided TT2 was given at least a month prior to delivery, or
DSWD. (2) Mother has received at least 3 doses of TT anytime prior to pregnancy
with this child.
Date Assess - refers to the month and year the child was classified as CPAB based on the definition.
Length - taken for children under 2 years of age
Height - taken for children 2 years and above
34
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART I
DATE COMPLEMENTARY
DATE IMMUNIZATION RECEIVED PNEUMOCOCCAL CHILD WAS EXCLUSIVELY BREASTFED****
FULLY ROTA VIRUS FEEDING*****
CONJUGATE VACCINES
(13) IMMUNIZED VACCINE
(PCV)
(15) (16) REMARKS
HEPA B1 PENTAVALENT OPV MCV CHILD Put a (√) check Put a Put a (√) check
BCG w/in More than MCV1 MCV2 (FIC) *** 1st 2nd 3rd 4th 5th Date for 6th 7th 8th
1 2 3 1 2 3 1 2 1 2 3
24 hrs. 24 hrs. (AMV) (MMR) (14) MO MO MO MO MO 6th mo. MO MO MO (17)
*** FULLY IMMUNIZED CHILD = is a child who has received all of the following antigens before reaching one year old: **** Exclusively breastfed - means no other food (including water) other
a) One (1) dose of BCG at birth or anytime, than breastmilk. Drops of vitamins and prescribed medication
b) Three (3) doses of OPV, three (3) doses of Pentavalent vaccines; and given while breastfeeding is still "exclusively breastfed."
c) One (1) dose of Measles-containing vaccine (MCV1). *****Complementary Feeding = infants 6-8 months who received solid,
semi-solid or soft foods to compliment breastfeeding.
*****Complementary Feeding = complementary foods & foods given

starting at 6 months to compliment breastfeeding.
Numerator: Infants 6-8 months who received solid, semi-solid or soft foods during the previous day
35
FHSIS v. 2012
TCL- 1
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART II
DATE OF MICRONUTRIENT SUPPLEMENTATION
LENGTH/HEIGHT
REGISTRATIO SEX (10) Dewor-
WEIGHT
DATE OF FAMILY
N COMPLETE VITAMIN A IRON MNP ming
BIRTH SERIAL NAME OF CHILD COMPLETE NAME OF MOTHER REMARKS
ADDRESS
(mm\dd\yy) NUMBER
6-11 12-59 mos. 6-11 12-59 6-11 12-23 12-59
(mm/dd/yy) (M/F)
(1) (2) (3) (4) (5) (6) (7) (8) (9) MOS. Dose 1 Dose 2 MOS. MOS. MOS. MOS. MOS. (12)
36
TARGET CLIENT LIST FOR
SICK CHILDREN
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL- SICK TARGET CLIENT LIST FOR SICK CHILDREN

DATE OF FAMILY DATE VITAMIN A SUPPLEMENTATION**
REGIS- SERIAL NAME OF CHILD OF BIRTH SEX COMPLETE ADDRESS (7)
TRATION NUMBER (mm/dd/yy) (M / F) Put a (√) check DIAGNOSIS/
DATE
mm/dd/yy 6-11 12-59 FINDINGS*
GIVEN
(1) (2) (3) (4) (5) (6) MOS. MOS. (use code)
* Diagnosis/Findings : ** Recommended Vitamin A Supplementation Given to High Risk/Sick Children

DIAGNOSIS PREPARATION PER CAPSULE VIT. A DOSAGE AND SCHEDULE OF ADMINISTRATION
A = Measles H = Corneal Xerosis Give one capsule upon diagnosis regardless of when the
B = Severe Pneumonia I = Corneal Ulcerations Measles cases 100,000 IU for infants 6-11 months old last dose of vitamin A capsule (VAC) was given.
C = Persistent Diarrhea J = Keratomalacia Give another capsule after 24 hours
D = Malnutrition Severe pneumonia, persistent diarrhea 200,000 IU for infants 12-59 months old Give one capsule upon diagnosis, except when the child
E = Xerophthalmia and severely underweight 100,000 IU for infants 6-11 months old was given VAC less than 4 weeks before diagnosis.
F = Night Blindness Cases with Xerophthalmia,including night 200,000 IU for infants 12-59 months old Give one capsule immediately upon diagnosis. Give one
G = Bitot's spots blindness, Bitot's spots, corneal xerosis, 100,000 IU for infants 6-11 months old capsule the next day, and 1 capsule 2 weeks after.
corneal ulcerations and keratomalacia 200,000 IU for infants 12-59 months old
38
TARGET CLIENT LIST FOR SICK CHILDREN
ANEMIC CHILDREN DIARRHEA CASES PNEUMONIA CASES
GIVEN IRON SUPPLEMENTATION *** (9) SEEN REMARKS
(8) AGE IN DATE GIVEN (10)
AGE IN MONTHS DATE MONTHS AGE IN DATE GIVEN
ORS/ORT W/
STARTED COMPLETED ORS MONTHS TREATMENT
ZINC
2-5 mos. 6-11 mos 12-59 mos 2-5 6-11 12-59 2-5 6-11 12-59 (11)
*** Iron Supplementation : DIAGNOSIS PREPARATION DOSAGE AND SCHEDULE OF ADMMINISTRATION

Drops 15 mg elemental Note: After completing 3 mos.
Dosage is 1 tsp. once a day for 3 months or 2 - 5 mos. w/ Low birth weight infa Give 0.3 ml once a day starting at 2 mos up to 6 mos. therapeutic supplementation infants
iron/0.6 ml
30 mg once a week for 6 months with supervised should continue preventive
6-11 mos old clinically diagnosed
administration. Give 3-6 mg/Kg/day elemental Iron in 3 divided doses a day for 3 supplementation regimen.
with Iron Deficiency Anemia s 15 mg elemental iron/0
mos. or : Give approximately 0.6ml 2-3
(IDA)
12-59 mos clinically diagnosed times a day for 3 mos.
Give approximately 5ml 2-3 times a day for 3 mos. If available,
with Iron Deficiency Anemia up 30 mg elemental Iron/
continue MNP supplementation after 3 mos.
(IDA)
39
FHSIS – DIC – 2012‐01
2.11 SUMMARY TABLES:
The Summary Tables are intended to record data in the facility to facilitate the capture and
recall of data.
2.11.1 Summary Table – Health Program Accomplishments
The Summary Table – Health Program Accomplishments is a health facility-based document

which records the performance of the barangay per month for one year, is filled up by the midwife,
and is her source of data for the Monthly Form. The table has provision for quarterly totals which
should be equivalent to the quarterly total of the PHN in her Consolidation Table. The quarterly totals
are also provided in this Summary Table so that the midwife can already make preliminary analysis of
her performance using these data.
Filling up the table
The first column lists exhaustively the indicators of your health service delivery in the barangay.
The next column is the “Target” column where you will place, at the start of the year, the targets of your
barangay for each Indicator. Please consult your PHN for the figure you will enter in this column.
Under each succeeding monthly columns, record the number being asked that corresponds to each
indicator for the month. Under each quarter, write the totals required.
2.11.2 Summary Table - Morbidity Report
The Summary Table – Morbidity Report records all the diseases that occur for the entire year.
The diseases are recorded on a monthly basis disaggregated by age group and sex. This Summary
Table shall also be the source of data for the Annual Report 2 – Morbidity Report.
Filling up the table
On the Summary Table – Monthly Morbidity, write on the space provided the month, the name
of disease and the number of cases per disease disaggregated by age group and sex.
2.12 MONTHLY CONSOLIDATION TABLE:
Monthly Consolidation Table - is a health facility-based document in which the PHN records the
report of the midwives in the municipality. At the end of every quarter, the PHN gets the totals of the
different indicators to fill-up the Quarterly form for submission to the PHO.
The month and year which corresponds to the Monthly Report of each Barangay. The first
column lists the indicators/diseases in the Monthly Form. On the succeeding column, write the name of
each BHS on top and the corresponding monthly data of each BHS.
40
Summary Table
for
BARANGAY
NAME OF BARANGAY:
NAME OF HEALTH CENTER:
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
2.13.1 MATERNAL CARE - PRENATAL and POSTPARTUM CARE
INDICATORS TARGET JAN FEB MAR 1st Q APR MAY JUNE 2nd Q JULY AUG SEPT 3rd Q OCT NOV DEC 4th Q TOTAL
PRENATAL CARE
1. Pregnant women with 4 or

more prenatal visits
2. Pregnant women given
2 doses of TT
TT2 plus
complete iron with folic acid
POSTPARTUM CARE
1. Postpartum women with
at least 2 PPV
2. Postpartum women
given complete iron
3. Women 10-49 years old given

Iron supplementation
4. Postpartum women
given Vitamin A
5. Postpartum women
initiated breastfeeding
STI SURVEILLANCE
1. No. of pregnant women seen
2. No. of pregnant women
tested for syphilis
positive for syphilis
4. No. of pregnant women (+)
for syphilis given Penicillin
42
2.13.2 FAMILY PLANNING (Part 1 of 2)
1. Current Users Beginning
► Female Sterilization
► Male Sterilization
► Pills
► IUD (PP-IUD/ I-IUD)
► Injectables (DMPA/CIC)
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
2. Total New Acceptors

► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
3. Total Other Acceptors
► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
43
2.14.3 FAMILY PLANNING (Part 2 of 2)
4. Total Drop-out
► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
5. Total Current Users
► Pills
► IUD
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
44
2.13.4 CHILD CARE (Part 1 of 3)
JAN FEB MAR 1st Q APR MAY JUN 2nd Q JUL AUG SEPT 3rdQ OCT NOV DEC 4thQ TOTAL
INDICATORS TARGET
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
1. Immunization given <1 yr
► BCG
w/in 24 hrs
► Hepa B1
> 24 hrs
► PENTA 2
► OPV 2
MCV1 (AMV)
► MCV
MCV2 (MMR)
1
► ROTA
2
► PCV 2
2. Fully Immunized Child
3. Completely Immunized
Child (12-23 mos)
4. Child Protected at Birth (CPAB)
45
INDICATORS TARGET
5. Infant age 6 mo. seen

6. Infant exclusively
breastfed until 6 mo.
7. Infants 6-8 months of age who
received solid, semi-solid and
soft food during previous day
8. Infant for newborn screening
● referred
● done
9. Infant/Children received Vit. A
● 6-11 mos.
● 12-59 mos.
10. Infant/Children received Iron
● 6-11 mos.
● 12-59 mos.
11. Infant/Children received MNP
● 6-11 mos.
● 12-23 mos.
12. Sick Children seen
● 6-11 mos.
● 12-59 mos.
13. Sick Children received Vit A
● 6-11 mos.
● 12-59 mos.
46
INDICATORS TARGET
14. Children 12-59 mos. old
given de-worming tablet/syrup
15. Infant 2-5 mos. w/ LBW seen
● received full dose Iron
16. Anemic infant
6-11 mos seen
Anemic children
12-59 mos seen
17. Diarrhea (0-59 mos. old)
● No. of Cases
● received ORS
● received ORT/ORS w/zinc
18. Pneumonia (0-59 mos. old)
● No. of Cases
● No with Completed Treatment
47
2.13.7 DENTAL HEALTH
INDICATORS TARGET
1. Orally Fit Child
12-71 mos. old
2. Child 12-71 mos
provided w/BOHC
3. Adolescent & Youth
(10-24 yo)given
BOHC
4. Preg women
provided w/BOHC
5. Older Person
60 yrs old & above
provided w/BOHC
48
2.13.8 MALARIA
INDICATORS
M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T
1.Total Population
2. Population at risk
3.Annual Parasite
Incidence
4. Total No. of
Confirmed Malaria
Cases
● < 5 yo
● ≥ 5 yo
● Pregnant
5. Total No of Lab
Confirmed Malaria
Cases by species
● P.falciparum
● P. vivax
● P.ovale
● P.malariae
6. Total No of
Confirmed Malaria
Cases by method
● Slide
● RDT
7. Total No. of LLIN
given
8. Total No. of
Malaria Deaths
49
2.13.9 TUBERCULOSIS
1st Q 2nd Q 3rd Q 4th Q TOTAL
INDICATORS
M F T M F T M F T M F T M F T
1. TB symptomatics who
underwent DSSM
2. Smear positive
discovered and identified
3. New smear positive

cases initiated tx and
registered
4. New smear (+) cases
cured
5. Smear(+) retreatment
cases cured
6. Smear (+) retreatment
cases initiated tx and
registered
● Relapse
● Treatment failure
● Return after default
● Other type of TB
7. No, of Smear (+)
retreatment cured
● Relapse

8.. Total No. of TB cases
(all forms) initiated tx
50
2.13.10 FILARIASIS
INDICATORS
Total Population
1.No. Cases with hydrocele,

lymphedema, Elephantiasis,
Chyluria
2. Clinical Rate
3. No of Cases examined
found positive for MF
5. Average MFD
6. Eligible population given

MDA (94.6% of TP)
7. Total population given MDA
51
2.13.11 LEPROSY
INDICATORS
1. Total Population
2. Total No. of Leprosy

cases (undergoing tx)
3. No. of Newly detected
Leprosy cases
► < 15 yo
► Grade 2 disability
4. No of Leprosy Cases
cured
52
2.13.12 SCHISTOSOMIASIS
INDICATORS
1. No. of
Symptomatic case
2. No. of Cases
Examined
3. No. of Positive
Cases
● Low intensity
● Medium intensity
● High intensity
4. No. of Cases
treated
5. No of Complicated
Cases
6. No. of Complicated
Cases referred to
hospital facility
53
2.13.13 MORBIDITY DISEASE REPORT FOR MONTH: ____________
NAME BY AGE-GROUP AND BY SEX
OF ICD Code Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & over TOTAL
DISEASE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
Acute Watery Diarrhea A09 (watery)

Acute Bloody Diarrhea A09 (bloody)
Inluenza-like Illness J11
Influenza J11
Acute Flaccid Paralysis G83.9
Acute Hemorrhagic Fever Syndrome (Dengue) A91
Acute Lower Respiratory Track Infection J22
Pneumonia J18.9
Cholera A00
Diphtheria A36
Filarisis B74
Leprosy A30
Leptospirosis A27
Malaria B50-B54
Measles B05
Meningococcemia A39
Neonatal Tetanus A33
Non-neonatal Tetanus A35
Paralytic Shellfish Poinosning T61.2
Rabies A82
Schistosomiasis B65
Typhoid and paratyphoid A01
Viral Encephalitis A83-86
Acute Viral Hepatitis B15-B17
Viral Meningitis A87
Syphilis A50-A53
Gonorrhea A54.9
Urethral Discharge R36
Genital Ulcer N48.5, N76.5, N76.6
54
2.13.14 MORBIDITY DISEASE REPORT FOR MONTH: ____________
OF Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & over TOTAL
55
2.13.15 NATALITY (from TCL) (Part 1 of 2)
INDICATORS TARGET
1. Livebirths (Total from
TCL)
2. Birthweight:
► 2500 grms &

greater
► Less than
2500 grams
► Not known
3. Attended by:
► Doctors
► Nurses
► Midwives
►Trained Hilot
► Others
► Unknown
56
NATALITY (from TCL) (Part 2 of 2)
JAN FEB MAR 1st Q APR MAY JUN 2nd Q JUL AUG SEP 3rd Q OCT NOV DEC 4th Q TOTAL
INDICATORS TARGET
4. Total No. of Deliveries
by Place:
►Health Facility
RHUs
 Hospitals
 BHS
 Lying-in
► Non-Institutional
Delivery (NID)
 Home
Others

by Type:
►Normal
►Operative
6. Total No. of Pregnancy

by outcome:
►Livebirth
►Fetal Deaths
►Abortion
57
2.13.17 NATALITY (from LCR) (Part 1 of 2)
INDICATORS TARGET
1. Livebirths (Total from

TCL)
2. Birthweight:
► 2500 grms &
greater
► Less than
2500 grams
► Not known
3. Attended by:
► Doctors
► Nurses
► Midwives
►Trained Hilot
► Others
► Unknown
58
2.13.18 NATALITY (from LCR) (Part 2 of 2)
INDICATORS TARGET
by Place
►Health Facility
RHUs
 Hospitals
 BHS
 Lying-in
► Non-Institutional
Delivery (NID)
 Home
Others

by Type:
►Normal
►Operative
6. Total No. of Pregnancy

by outcome:
►Livebirth
►Fetal Deaths
►Abortion
59
2.13.19 ENVIRONMENTAL HEALTH
1. Households with access

to improved water
● Level I
● Level II
● Level III
2. HH w/sanitary toilet
3. HH w/satisfactory
disposal of solid waste
4. HH w/complete basic
sanitation facilities
5. Food Establishment
6. Food Establishment w/
sanitary permit
7. Food Handlers
8. Food Handlers with
health certificates
9. Salt Samples Tested
10. Salt Samples Tested
found (+) for iodine
60
2.13.20 MORTALITY (From LCR or RHU log books)
INDICATORS TARGET
1. Total Deaths
2. Infant Deaths
3. Maternal Deaths
4. Neonatal Deaths
5. Deaths due to
neonatal tetanus
6. Perinatal Deaths
7. Deaths among
children under 5
years of age
61
2.13.21 PROGRAM: ______________________________
ACTIVITIES TARGET
62
Monthly Consolidation Table
for
HEALTH CENTER
NAME OF HEALTH CENTER:
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
2.14.1 MATERNAL CARE Month: Year: ____________
N A M E OF B A R A N G A Y
INDICATORS
1. Pregnant women
● W/4 or more prenatal visits

● Given 2 doses of TT
● Given TT2 plus
● Given complete iron with

folic acid
2. Postpartum women
● With at least 2 PPV
● Given complete iron
● Women 10-49 years old
given Iron supplementation
● Given Vitamin A
● Initiated Breastfeeding
3. No. of pregnant women seen

tested for SYPHILIS

positive for SYPHILIS
given Penicillin
64
Month: _____________ Year: ___________________
Total
65
2.14.2 FAMILY PLANNING (Part 1 of 3) Month:__________________ Year: ___________________
INDICATORS
1. Total Current Users beginning

► Female Ster/BTL
► Male Ster/Vasectomy
► Pills
► IUD (P-IUD and I-IUD)
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
2. Total New Acceptors

► Female Ster/BTL
► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
66
Month: _____________ Year: ___________________
67
2.14.3 FAMILY PLANNING (Part 2 of 3) Month: _____________ Year: ___________________
INDICATORS
3. Total Other Acceptors

► Female Ster/BTL
► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
4. Drop-Out
► Female Ster/BTL
► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
68
Month: _____________ Year: ___________________
69
2.14.4 FAMILY PLANNING (Part 3 of 3) Month: _________________ Year: ___________________
INDICATORS
5. Total Current Users
► Female Ster/BTL
► Pills
► NFP-CM
► NFP-BBT
► NFP-STM
► NFP-SDM
► NFP-LAM
► Condom
► Implant
70
Month: _____________ Year: ___________________
71
2.14. CHILD CARE (Part 1 of 3) Month:__________________ Year: ___________________
INDICATORS
1. Immunization given <1 yr:

► BCG
w/in 24 hrs
► Hepa B1
> 24 hrs
1
► PENTA 2
3
1
► OPV 2
3
MCV1 (AMV)
► MCV
MCV2 (MMR)
1
► ROTA
2
1
► PCV 2
3
2. Fully Immunized Child
3. Completely Immunized Child (12-23 mos)
4. Child Protected at Birth (CPAB)
72
Month: ___________________ Year: ___________________
Total
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
73
2.14.6 CHILD CARE (Part 2 of 3) Month:__________________ Year: ___________________
INDICATORS
5. Infant age 6 mos. Seen
6. Infant exclusively breastfed
until 6 months
7. Infants 6-8 months of age who
received solid, semi-solid and soft
food during previous day
8. Infant referred for
newborn screening
9. Infant/Children received Vit. A
● 6-11 mos.
● 12-59 mos.
10. Infant/Children received Iron
● 6-11 mos.
● 12-59 mos.
11. Infant/Children consumed MNP
● 6-11 mos.
● 12-23 mos.
12. Sick Children seen
● 6-11 mos.
● 12-59 mos.
13. Sick Children received Vit. A
● 6-11 mos.
● 12-59 mos.
74
Month: _____________________ Year: ___________________
Total
75
2.14. CHILD CARE (Part 3 of 3) Month: _____________ Year: ___________________
INDICATORS
14. Children 12-59 mos. old
given de-worming tablet
15. Infant 2-5 mos. w/ LBW seen
16. Anemic Children
6-11 mos seen
Anemic children
12-59 mos seen
17. Diarrhea (0-59 mos. old)
● No. of Cases
● received ORS
● received ORS/ORT w/zinc
18. Pneumonia (0-59 mos. old)

● No. of Cases
● No. Completed Treatment
76
Month: _____________ Year: ___________________
Total
77
2.14. LEPROSY Month:___________________________ Year: ___________________
INDICATORS
1. Total Population
2. Total No. of Leprosy cases

(undergoing treatment)
Leprosy cases
► < 15 yo
4. No. of Leprosy Cases cured
78
Month:___________________________ Year: ___________________
Total
79
2.14. TUBERCULOSIS Month:___________________________ Year: ___________________
INDICATORS
1. TB symptomatics who
underwent DSSM
2. Smear positive discovered

and identified
3. New smear positive cases

initiated treatment and
registered
4. New smear (+) cases cured
5. Smear(+) retreatment cases

cured
6. Smear (+) retreatment cases

initiated treatment and
registered
● Relapse
7. No. of Smear (+)
retreatment cured
● Relapse
8. Total No. of TB cases (all
forms) initiated treatment
9. TB All forms identified
10. Case Detection Rate
80
Month:___________________________ Year: ___________________
Total
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
81
2.14.1 MALARIA Month:___________________________ Year: ___________________
INDICATORS
1.Total Population
2. Population at risk
3.Annual Parasite Incidence
4. Total No. of Confirmed
Malaria Cases
● < 5 yo
● ≥ 5 yo
● Pregnant
5. Total No. of Lab Confirmed

Malaria Cases by species
● P.falciparum
● P. vivax
● P.ovale
● P.malariae
7. Total No. of Confirmed

Malaria Cases by method
● Slide
● RDT
8. Total No. of LLIN given
9. Total No. of Malaria Deaths
82
Month:___________________________ Year: ___________________
Total
83
2.14.1 FILARIASIS Month:___________________________ Year: ___________________
INDICATORS
1. No. Cases with hydrocele,

lymphedema, Elephantiasis,
Chyluria
2. Clinical Rate
3. No. of Case examined
4. No. of Cases examined
found Positive for MF
5. Average MFD
6. Eligible population given

MDA (94.6% of TP)
84
Month:___________________________ Year: ___________________
Total
85
2.14.1 SCHISTOSOMIASIS Month:___________________________ Year: ___________________
INDICATORS
1. No. of Symptomatic cases
2. No. of Cases Examined
3. No. of Positive Cases
● Low intensity
● Medium intensity
● High intensity
4. No. of Cases treated
5. No. of Complicated Cases

6. No. of Complicated Cases
referred
86
Month:___________________________ Year: ___________________
Total
87
2.14.1 DISEASE: ________________________________ Month:___________________________ Year: ___________________
AGE GROUP
Under 1 year
1-4
5 -9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 and 0ver
TOTAL
88
Month:___________________________ Year: ___________________
TOTAL
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
89
2.14.15 PROGRAM: __________________________________
ACTIVITIES
90
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FHSIS – DIC – 2012‐01
2.15 THE MONTHLY FORM FOR PROGRAM REPORT (M1):

The Monthly Form is the reporting form that the midwife fills up to report her accomplishments
from the first day to the last day of the month and submits to the nurse at the RHU/MHC for
consolidation. Spaces are left blank for those indicators the municipality/city needs to generate at their
level.

Heading ‐ Fill up the data asked for in the heading: the Month being reported and the Year, the name of
the Barangay, Name of BHS, the Municipality or City, Province and the Projected Population of the
Barangay (except during National Census years).

2.15.1 Maternal Care

 Pregnant women with 4 or more prenatal visits – write on the space provided the total number of
pregnant women who had 4 or more prenatal visits during the month/quarter such that at least
one visit occurs during the first trimester, one during the second trimester and at least 2 visits
during the third trimester.

 Pregnant women given 2 doses of Tetanus Toxoid – write on the space provided the total number of
pregnant women given 2 doses of Tetanus Toxoid during the month/quarter.

 Pregnant women given TT2 plus – write on the space provided the total number of pregnant women
given TT2 plus during the month/ quarter. TT2 plus includes 2nd, 3rd, 4th and 5th doses of Tetanus
Toxoid given to pregnant women.

 Pregnant women given complete iron with folic acid supplementation – write on the space provided
the total number of pregnant women given complete tablet of 60 mg of Fe with 400 mcg Folic
acid, once a day for 6 months or 180 tablets. The iron tablets referred to are those given for
free to the mother by the RHUs and BHSs and do not include prescribed iron tablets. Iron tablet
should be given as soon as pregnancy was diagnosed. If the pregnant women did not take full
course of the 180 tablets, she will not be included in the report.

 Post partum women with at least 2 post‐partum visits – write on the space provided the total number
of post‐partum women who were seen by the midwife/PHN/MHO at home or at the clinic twice
or more than twice after delivery such that first visit should be within 24 hours upon delivery
and the second visit within one week after delivery.

 Post partum women given complete iron supplementation – write on the space provided the total
number of post‐partum women given complete tablet of 60 mcg of Fe with 400 mcg Folic acid,
once a day for 3 months or a total of 90 tablets. If postpartum mother did not take full course of
90 tablets, she will not be included in the report.

 Women 10‐49 years old given Iron supplementation – write on the space provided the total number
of women given Iron supplementation

 Post partum women given Vitamin A supplementation – write on the space provided the total number
of post‐partum or lactating women given 200,000 I.U. of Vitamin A capsule within 4 weeks after
delivery

 Post partum women initiated breastfeeding within 1 hour after delivery – write on the space
provided the total number of post‐partum or lactating women who initiated breastfeeding
within 1 hour after giving birth.

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FHSIS – DIC – 2012‐01
2.15.2 STI Surveillance

 Number of pregnant women – write on the space provided the total number of pregnant women seen
in the health center.

 Number of pregnant women tested for Syphilis (SY) – write on the space provided the total number of
pregnant women tested for Syphilis.

 Number of pregnant women positive for Syphilis – write on the space provided the total number of
pregnant women tested positive for Syphilis.

 Number of pregnant women with Syphilis given Penicillin – write on the space provided the total
number of pregnant women with Syphilis given Penicillin.

2.15.3 Family Planning

 Current Users (Beginning Month) – write on the space provided the total number of FP clients who
have been carried over from the previous month

 Acceptors –

 New Acceptors of previous month ‐ write on the space provided the number of new acceptors
from previous month.
 Other Acceptors of present month – write on the space provided the number of clients who are
Changed Method, Changed Clinic and Restart.

 Drop‐outs (present month) – write on the space provided the number of clients who drop‐out during
the month.

 Current Users (End Month) – write on the space provided the total number of FP clients who have
been carried over from the previous month after deducting the drop‐outs of the present month,
adding the new acceptors of the previous month and adding the other acceptors (RS,CC,CM).
This consists of CU for pills, IUD, injectables, condom, NFP (BBT, CM, STM, SDM and LAM),
female sterilization, male sterilization and implants.

(Note: In preparing the monthly report for this portion, the midwife in the BHS/Barangay will
prepare the monthly data only.) Memo to be posted

Calculation sample for Month of February Report :

Current users from the previous month (Jan 2012) 29
+ New Acceptors previous month (Jan 2012) + 6
+ Other Acceptors of the present month (Feb 2012) + 4
‐ Drop‐outs present month (Feb 2012) ‐ 2
= Current Users ending month of Feb 2012 = 37

*See Annex 1 for the Calculation of the Current Users

 New Acceptors of the present month ‐ using a family planning method for the first time or a client
who has never accepted any modern family planning method at any clinics before (new to the
program). It includes new acceptors for pills, IUD, injectables, condom, NFP (BBT, CM, STM,
and SDM), LAM, implants, Female STR and Male STR.

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FHSIS – DIC – 2012‐01
2.15.4 Child Care

 Immunization by antigen (BCG, PENTA1 to PENTA3, OPV1 to OPV 3, Hepatitis birth dose within 24
hours after birth or after 24 hours after birth, ROTA1 to ROTA2, anti‐Measles vaccine and
measles‐mumps‐rubella (MMR)) – write on the space provided the total number of infants 0‐11
months who were given the specific antigen during the month/quarter.

 Fully Immunized Child – write on the space provided the total number of children 0‐11 months that
have completed their immunization schedule during the month/quarter. To be fully immunized,
the child must have been given BCG, 3 doses of PENTA, 3 doses of OPV, and one dose of anti‐
measles vaccine before reaching 1 year of age. The child is counted as FIC as soon as all the
required vaccines are administered without waiting for the child to reach 1 year of age.

 Completely Immunized Child (12‐23 mos.) – write on the space provided the total number of children
12‐23 months of age who completed their immunization schedule during the month/quarter.
To be completely immunized, the child must have been given BCG, 3 doses of PENTA, 3 doses of
OPV, and one dose each of anti‐measles vaccine and MMR.

 Child Protected at Birth (CPAB) – write on the space provided the total number of children whose (1)
Mother has received 2 doses of TT during this pregnancy, provided TT2 was given at least a
month prior to delivery, or (2) Mother has received at least 3 doses of TT anytime prior to
pregnancy with this child. If the mother received TT2 only for this child, write the month and
year TT2 was given.

 Infants 6 months of age seen ‐ write on the space provided the total number of infants seen at 6th
month at the facility or during home visit.

 Infants exclusively breastfed until 6 months ‐ write on the space provided the total number of infants
seen to be exclusively breastfed from birth up to 6th months. Exclusively breastfeeding is giving
no other food (including water) other than breast milk. Drops of vitamins and prescribed
medication (by doctor only) given while breastfeeding is still “exclusive BF”.

 Infants given complimentary food 6–8 months ‐ write on the space provided the total number of
infants given complimentary food from 6‐8 months of age.

 Infant referred for newborn screening ‐ write on the space provided the total number of infants given
referral for newborn screening.

 Infant 6‐11 months old given Vitamin A ‐ write on the space provided the total number of infants 6‐11
months old given Vitamin A supplementation. Vitamin A supplementation refers to 1 dose of
100,000 I.U. One capsule is given anytime during the 6‐11 months.

 Children 12‐59 months old given Vitamin A ‐ write on the space provided the total number of children
12‐59 months old given Vitamin A Supplementation. Vitamin A supplementation refers to
200,000 I.U. Dosage and duration is 1 capsule every six months.

 Infant 6‐11 months old given Iron ‐ write on the space provided the total number of infants given Iron
supplement.

 Children 12‐59 months old given Iron ‐ write on the space provided the total number of children given
Iron supplement.

 Infants 6‐11 months old received MNP ‐ write on the space provided the number of infants whose ages
range from 6 to 59 months received MNP. 60 sachets were given anytime during 6‐11 months.

 Children 12‐23 months old received MNP ‐ write on the space provided the number of children whose
94
FHSIS – DIC – 2012‐01
ages range from 12 to 23 months received MNP. 120 sachets were given anytime during 12‐23
months children

 Children 12‐59 mos. old given de‐worming tablet ‐ write on the space provided the number of children
whose ages range from 12 to 59 months received de‐worming tablet.

 Sick Children 6‐11 and 12‐59 months old seen ‐ write on the space provided the number of sick
children whose ages range from 6 to 11 months and 12‐59 months old seen during the
month/quarter. High Risk or Sick Children are those with the following categories: (1) severe
pneumonia (2) persistent diarrhea (3) measles (4) severely under weight and (5) Cases with
Xerophthalmia, including night blindness, Bitot’s spots, corneal xerosis, corneal ulcerations,
keratomalacia and corneal scar.

 Sick Children 6‐11 months old given Vitamin A ‐ Write on the space provided the number of sick
children whose age range from 6 to 11 months and were given Vitamin A during the
month/quarter. Dosage of Vitamin A for 6‐11 months old infants is 100,000 IU.
NOTE: Vitamin A given during Garantisadong Pambata should not be included in this report.

 Sick Children 12‐59 months old given Vitamin A ‐ write on the space provided the number of sick
children whose ages range from 12 to 59 months old and were given Vitamin A capsule during
the month. Dosage of Vitamin A for 12‐59 months old children is 200,000 IU (1 capsule every 6
months). NOTE: Vitamin A given during Garantisadong Pambata should not be included in this
report.

 Infant 2‐5 months old with low birth weight ‐ write on the space provided the number of infant
whose ages range from 2 to 6 months old with low birth weight seen during the month/quarter.
Low birth weight (LBW) Infant refers to infant with birth weight less than 2.5 kilograms or 2,500
grams.

 Infant 2‐5 months old with low birth weight given iron supplements ‐ write on the space provided the
number of infants whose ages range from 2 to 6 months old with low birth weight and was given
iron during the month/quarter. Dosage is 0.3 ml once a day to start at two months of age until 6
months when complementary foods are given. (Preparation is 15 mg. elemental iron/0.6 ml).

 Anemic Children 6‐11 months and 12‐59 months old seen ‐ write on the space provided the number of
anemic children whose ages range from 2 to 59 months old seen during the month/quarter. 6‐
11 months – drops 12‐59 months syrup/MNP

 Anemic Children 6‐11 months and 12‐59 months old seen given iron supplements ‐ write on the space
provided the number of anemic children whose ages range from 2 to 59 months old and was
given iron supplementation during the month/quarter. Dosage is 1 tsp. once a day for 3 months
or 30 mg. once a week for 6 months with supervised administration.

 Diarrhea cases 0‐59 months old seen ‐ write on the space provided the total number of diarrhea
children 0‐59 months old seen during the month/quarter.

 Diarrhea cases 0‐59 months old given ORS ‐ write on the space provided the total number of diarrhea
children whose ages range from 0 to 59 months old and was given ORS during the
month/quarter.

 Diarrhea cases 0‐59 months old given ORS/ORT with zinc ‐ write on the space provided the total
number of diarrhea children whose ages range from 0 to 59 months old and was given ORS with
zinc during the month/quarter. Dosage for children less than 6 months is 10 mg. elemental
Zn/day and for children more than 6 months is 20 mg elemental Zn/day x 10‐14 days.

 Pneumonia cases 0‐59 months old seen ‐ write on the space provided the total number of children 0‐
95
FHSIS – DIC – 2012‐01
59 months old seen with pneumonia during the month/quarter.

 Pneumonia cases 0‐59 months old given treatment ‐ write on the space provided the total number of
children 0‐59 months old seen with pneumonia and was given antibiotic treatment during the
month/quarter.

2.15.5 Malaria

• Malaria cases among less than 5 years of age and above 5 years of age – write on the space provided
the total number of malaria cases among less than 5 years of age and above 5 years of age.

• Laboratory Confirmed malaria cases by species: P. falciparum, P. vivax, P. malariae, P. ovale – write
on the space provided the total number of malaria cases by species by sex and pregnant women
(P. falciparum, P.vivax, P.malariae, P.ovale). In column 1, write the total number of male clients
confirmed positive of malaria (P. falciparum, P. vivax, P. malariae, P. ovale). In column 2, write
the total number of female clients confirmed positive of malaria excluding pregnant women (P.
falciparum, P. vivax, P. malariae, P. ovale). While in column 3, write the total number of pregnant
women positive of malaria (P. falciparum, P. vivax, P. malariae, P. ovale). (See Annex 2.9 ITR
Malaria Prevention and Control Program )

• Confirmed malaria cases by method: Slide and Rapid Diagnostic Test (RDT) – write on the space
provided the total number of malaria cases by method (slide and RDT). (See Annex 2.9 ITR
Malaria Prevention and Control Program)

• Households at risk – write on the space provided the total number of households at risk of malaria.

• Households given Long Lasting Insecticide Nets (LLIN) – write on the space provided the total number
of households given long lasting insecticide nets.

2.15.6 Tuberculosis

• TB symptomatics who underwent Direct Sputum Smear Microscopy (DSSM) – write on the space
provided the total number of person who present symptoms or signs suggestive of TB, in
particular cough or long duration (2 or more weeks of cough). In this column, write the total
number of persons with TB symptomatics who underwent DSSM regardless of the results. (See
Annex 2.8 ITR Tuberculosis Prevention and Control Program)

• Smear positive (+) discovered – write on the space provided the number of patient with the following:
(See Annex 2.8 ITR Tuberculosis Prevention and Control Program)

1. at least 1 sputum specimens positive for Acid Fast Bacilli (AFB) on direct sputum smear
microscopy with or without radiographic abnormalities consistent with active TB; or
2. with one sputum specimen positive for AFB and with radiographic abnormalities
consistent with active TB as determined by clinician ; or
3. with one sputum specimen positive for AFB with sputum culture positive of
Mycobacterium tuberculosis

 All forms of TB cases – write on the space provided the number of persons who are case positive
classified as both Pulmonary and Extra‐pulmonary. (See Annex 2.8 ITR Tuberculosis Prevention
and Control Program)

• New Smear (+) cases initiated treatment ‐ . New smear positive cases are TB patients that have not
taken anti‐TB drugs before or if they have taken anti‐TB drugs for less than 1 month. Write on
the space provided the number of new smear positive cases given treatment and registered in
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FHSIS – DIC – 2012‐01
a DOT facility. (See Annex 2.8 ITR Tuberculosis Prevention and Control Program)

• New smear positive cases cured – write on the space provided the number of new smear positive cases
who have completed treatment and is smear negative in the last month of treatment and on at
least one previous occasion in the continuation phase. (See Annex 2.8 ITR Tuberculosis
Prevention and Control Program)

• Smear positive re‐treatment cases initiated treatment – write on the space provided the number of
smear positive re‐treatment cases given treatment and registered in a DOTS facility Re‐
treatment cases refer to Relapse, Return after Default, Treatment Failure and Other type of TB
cases (See Annex 2.8 ITR Tuberculosis Prevention and Control Program)

 Relapse
 Treatment failure
 Return after default
 Other types of TB

 Smear positive re‐treatment cases who got cured ‐ write on the space provided the number of sputum
smear positive (+) re‐ treatment patient who has completed treatment and is now sputum
smear negative (‐) in the last month of treatment and on at least one previous occasion in the
continuation phase. (See Annex 2.8 ITR Tuberculosis Prevention and Control Program)

 Relapse
 Treatment failure
 Return after default

2.15.7 Schistosomiasis
 Symptomatic Case ‐ write on the space provided the number of schistosomiasis cases. (See Annex 2.11
Schistosomiasis Prevention and Control Program)

 Positive Case ‐ write on the space provided the number of schistosomiasis cases found positive. (See
Annex 2.11 Schistosomiasis Prevention and Control Program)

 Case infected with low, medium and high intensity ‐ write on the space provided the number of
schistosomiasis cases with low, medium and high intensity. (See Annex 2.11 Schistosomiasis
Prevention and Control Program)

 Cases treated ‐ write on the space provided the number of schistosomiasis cases treated. Treatment of
cases is the administration of Praziquantel, 600 mg given just one day in 2‐3 divided doses at 40‐
60 mg/kg. (See Annex 2.11 Schistosomiasis Prevention and Control Program)

 Cases referred to hospital facilities ‐ write on the space provided the number of schistosomiasis cases
referred to hospital facilities. (See Annex 2.11 Schistosomiasis Prevention and Control Program)
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FHSIS – DIC – 2012‐01

 Cases examined – number of stool smear examined. (See Annex 2.11 Schistosomiasis Prevention and Control
Program)
2.15.8 Filariasis

 Case examined ‐ write on the space provided the number of blood smears examined. (See Annex 2.12
Filariasis Prevention and Control Program)
 Case positive (+) ‐ write on the space provided the number of blood smears positive for microfilariae. (See
Annex 2.12 Filariasis Prevention and Control Program)
 Clinical Cases ‐ write on the space provided the number of patients with lymphedema, elephantiasis,
hydrocele, and chyluria.
 Person given Multi‐Drug Administration ‐ write on the space provided the number of persons given Multi‐
Drug Administration.
 Eligible population – write the population of persons with age 2 yrs. & above.
2.15.9 Leprosy

 Leprosy Cases ‐ write on the space provided the number of leprosy cases. Include both multibacilliary (MB)
and paucibacillary (PB). (See Annex 2.10 ITR Leprosy Prevention and Control Program)
 Leprosy Cases below 15 years of age ‐ write on the space provided the number of newly diagnosed leprosy
cases below 15 years of age include both multibacilliary (MB) and paucibacillary (PB). (See Annex 2.10
ITR Leprosy Prevention and Control Program)
 Newly Detected Leprosy Cases ‐ write on the space provided the number of newly detected leprosy cases.
Include both multibacilliary (MB) and paucibacillary (PB).(See Annex 2.10 ITR Leprosy Prevention and
Control Program)
 Newly Detected Leprosy Cases with Grade 2 disability ‐ write on the space provided the number of newly
detected leprosy cases with Grade 2 disability. Include both multibacilliary (MB) and paucibacillary
(PB). (See Annex 2.10 ITR Leprosy Prevention and Control Program)
 Cases Cured ‐ write on the space provided the number of leprosy cases who have received a complete
treatment for TB patients 6 blister packs and for MB patients 12 blister packs. (See Annex 2.10 ITR
Leprosy Prevention and Control Program)

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FHSIS – DIC – 2012‐01

2.16 THE MONTHLY REPORT OF MORBIDITY DISEASES (M2):

The Monthly Report of Morbidity Diseases contains a list of all diseases by age and sex. It summarizes
the monthly report of morbidity diseases. The Midwife forwards this report to the PHN at the RHU/MHC.

a. Heading
Write the full name of the BHS/BHC, RHU/MHC, the month and the year for which the report
is being prepared.

b. Filling up the report
List all diseases encountered in your area and for each disease write on the space provided
the month total number of males (M) and females (F) for the corresponding age grouping.

99

FHSIS version 2012
FHSIS REPORT for the MONTH___________ YEAR: _______

Name of BRGY: ____________________________________
Name of BHS: _____________________________________
Municipality/City of: __________________________________
Province: _________________________________________
Projected Population of the Year: _______________
For submission to RHU
MATERNAL CARE No.

Pregnant women with 4 or more Prenatal visits
Pregnant women given 2 doses of Tetanus Toxoid
Pregnant women given TT2 plus
Preg. women given complete iron w/ folic acid supplementation
Postpartum women with at least 2 postpartum visits
Postpartum women given complete iron supplementation
Postpartum women given Vitamin A supplementation
PP women initiated breastfeeding w/in 1 hr. after delivery
Women 10-49 years old given Iron supplementation
Deliveries
Acceptors New
Current User Dropout Current User Acceptors
FAMILY PLANNING METHOD (Beginning New Other (Present (End of of the
Month) Acceptors Acceptors Month) Month) present
(Previous (Present Month
Month) Month)
a. Female Sterilization/BTL
b. Male Sterilization/Vasectomy
c. Pills
d. IUD (Intrauterine Device)
e. Injectables (DMPA/CIC)
f. NFP-CM (Cervical Mucus)
g. NFP-BBT (Basal Body Temperature)
h. NFP-STM (Symptothermal Method)
i. NFP-SDM (Standard Days Method)
j. NFP-LAM (Lactational Amenorrhea Method)
k. Condom
l. Implant
Total
Note: Have a separate report for new acceptors for the month/quarter for method. SEE BACK PAGE
100
M1-Form page 2
CHILD CARE Male Female Total CHILD CARE Male Female Total
Immunization given <1 yr Infant given complimentary food from 6-8 months
● BCG Infant for newborn screening : referred
: done
w/in 24 hrs. Infant 6-11 months old received Vitamin A
● Hepa B1
> 24 hrs. Chidren 12-59 months old received Vitamin A
1 Infant 6-11 months old received Iron
● PENTA 2 Children 12-59 months old received Iron
3 Infant 6-11 months received MNP
1 Children 12-23 months received MNP
● OPV 2 Sick Children 6-11 months seen
3 Sick Children 6-11 months received Vitamin A
MCV1 (AMV) Sick Children 12-59 months seen
● MCV
MCV2 (MMR) Sick Children 12-59 months received Vitamin A
1 Children 12-59 mos. old given de-worming tablet/syrup

● ROTA 2 Infant 2-5 mos w/ Low Birth Weight seen
3 Infant 2-5 mos w/ LBW received full dose iron

1 Anemic Children 6-11 months old seen
● PCV 2 Anemic Children 6-11 mos received full dose iron
3 Anemic Children 12-59 months old seen

Fully Immunized Child (0-11 mos) Anemic Children 12-59 mos received full dose iron
Completely Immunized Child(12-23 mos) Diarrhea cases 0-59 months old seen
Total Livebirths Diarrhea cases 0-59 mos old received ORS
Child Protected at Birth (CPAB) Diarrhea 0-59 mos received ORS/ORT w/ zinc
Infant age 6 months seen Pneumonia cases 0-59 months old
Infant exclusively breastfed until 6th month Pneumonia cases 0-59 mos. old completed Tx
MALARIA Male Female Total SCHISTOSOMIASIS Male Female Total
Total Population No. of symptomatic case

Population at risk No. of cases examined
Annual Parasite Incidence No. of positive cases
Confirmed Malaria Cases ● Low intensity
● < 5 yo ● Medium intensity
● ≥ 5 yo ● High intensity
● Pregnant No. of cases treated
Confirmed malaria cases No. of complicated cases
By Species: ● P. falciparum No. of complicated cases referred
● P. vivax
FILARIASIS Male Female Total
● P. ovale
● P. malariae No. of cases w/ Hydrocele, Lymphedema,
By Method: ● Slide Elephantiasis & Chyluria
● RDT No. of cases Examined
Malaria Deaths Clinical Rate
Number of LLIN given No. of cases examined found positive for MF
Average MFD
TUBERCULOSIS Male Female Total
Eligible population given MDA (94.6% of TP)
1. TB symptomatics who underwent DSSM Total population given MDA
2. Smear positive discovered and identified
LEPROSY Male Female Total
3. New smear (+) cases intiated tx & registered
4. New smear (+) cases cured Total Population
5. Smear (+) retreatment cases cured Total no. of Leprosy cases (undergoing treatment)
6. Smear (+) retreatment cases initiated tx & registered No. of Newly detected Leprosy cases
 Relapse ● < 15 yo
 Treatment failure ● Grade 2 disability
 Return after Default No. of Leprosy cases cured
 Other type of TB
STI SURVEILLANCE Male Female Total
7. No. of Smear (+) retreatment cured
 Relapse No. of pregnant women seen
 Treatment failure No. of pregnant women tested for Syphilis
 Return after Default No. of pregnant women positive for Syphilis
8. Total No. of TB cases (all forms) initiated treatment No. of pregnant women given Penicillin
10. Case Detection Rate
101
2.18 Morbidity Disease Report (M2)
. FHSIS v. 2012
M2
FHSIS Monthly Report for : Year:
Name of BRGY and BHS:
Catchment Health Center:
MORBIDITY DISEASES REPORT

For submission to the RHU
ICD 10 Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 & above TOTAL
DISEASE
CODE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Total
Influenza J11
Acute Hemorrhagic Fever Syndrome
A91
(Dengue)
Pneumonia J18.9
Cholera A00
Diphtheria A36
Filarisis B74
Leprosy A30
Leptospirosis A27
Malaria B50-B54
Measles B05
Meningococcemia A39

Rabies A82
Schistosomiasis B65
Syphilis A50-A53
Gonorrhea A54.9
Genital Ulcer N48.5, N76.5, N76.6,
102
. FHSIS v.2008
FHSIS MONTHLY REPORT for: Year:

Name of BRGY and BHS:
Catchment Health Center:
For submission to RHU
Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 & above TOTAL

DISEASE
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
103
FHSIS – DIC – 2012‐01

2.19 THE QUARTERLY FORM FOR PROGRAM REPORT (Q1):

The Quarterly Form is the official health report of the municipality/city for the quarter. It contains the
consolidated three month reports of all the BHSs and the RHU/MHC for health service delivery during the
quarter. The PHN forwards this report to the Provincial FHSIS Coordinator at the PHO every third week of the
first month of the succeeding quarter for provincial consolidation. The municipality/city prepared only one
quarterly report. In case there is more than one RHU/MHC in the municipality/city, the MHO/CHO who sits as
the vice chairman of the LHB shall be responsible for directing the consolidation of all the quarterly data from
different RHUs/MHCs and the preparation of one Quarterly Form for the municipality/city. Spaces are left
blank for those indicators the municipality/city wants to generate based on their local needs and interests.

Heading ‐ Fill up the heading with the data being asked for: Identify the Quarter and Year. Place full name of
the Municipality/City and the Province to which the LGU belongs.

Projected population for the year ‐ write on the space provided the city or municipality population.

Filling up the form ‐ The Quarterly Form is designed by program with the indicators listed in the first column,
followed by the eligible population, number of male and female cases, the total for both sexes, the
percentage accomplishment, the interpretation or analysis of data and recommendations or actions
taken by your area. Denominators for some indicators are listed below for easy computation. All
indicators found in the Monthly Form should have the same definitions except for Dental Health
which can only be found in the Quarterly Form.

2.19.1 Maternal Care –Put the totals for the quarter per indicator and place Interpretation and
Recommendations/Actions taken.
2.19.2 Family Planning –Put the totals for the quarter per indicator and place Interpretation and
2.19.3 Child Care –Put the totals for the quarter per indicator and place Interpretation and

2.19.4 Dental Care

 Orally Fit Children 12‐71 months old ‐ write on the space provided the number of children whose ages
ranges from 12 to 71 months old and meet all of the following upon oral examination and/or
completion of treatment: (1) caries‐free or decayed teethy filled (permanent fillings)(2) has healthy
gums (3) no oral debris and (4) no dento‐facial anomaly that limits normal function.(See Annex 2.7
Dental Health Program form 1)Place Interpretation and Recommendations/Actions taken.

 Children 12‐71 months old provided with Basic Oral Health Care (BOHC) ‐ write on the space provided the
number of children whose ages ranges from 12 to 71 months old and were provided with Basic Oral
Health Care during the quarter. Basic Oral Health Care refers to one of more of the following services:
(1) Oral Examination (2) 80% Attendance to Supervised Tooth Brushing (3) Atraumatic Restorative
Treatment (ART) and (4) Oral Urgent Treatment (OUT) which includes removal of unsavable teeth or
referral of complicates cases of treatment of post‐extraction complications or drainage of localized
oral abscess. (See Annex 2.7 Dental Health Program form 1) Place Interpretation and

 Adolescent and Youth (10‐24 years old) provided with Basic Oral Health Care (BOHC) ‐ write on the space
provided the number of youth and adolescents whose ages ranges from 10 to 24 years old and were
provided with Basic Oral Health Care during the quarter. Basic Oral Health Care refers to one of more
of the following services: (1) Oral Examination (2) Education and counseling on health effects of
tobacco/smoking, diet and oral hygiene. (See Annex 2.7 Dental Health Program form 1) Place
104
FHSIS – DIC – 2012‐01
Interpretation and Recommendations/Actions taken.

 Pregnant women provided with Basic Oral Health Care (BOHC) ‐ write on the space provided the number of
pregnant women who were provided with Basic Oral Health Care during the quarter. Basic Oral Health
Care refers to one of more of the following services: (1) Oral Examination (2) Scaling (3) Permanent
Filling and (4) Gum Treatment. (See Annex 2.7 Dental Health Program form 1) Place Interpretation and

 Older Persons 60 years old and above provided with Basic Oral Health Care (BOHC) ‐ write on the space
provided the number of older persons ages 60 years old and above who were provided with Basic
Oral Health Care during the quarter. Basic Oral Health Care refers to one of more of the following
services: (1) Oral Examination (2) Extraction and (3) Gum Treatment. (See Annex 2.7 Dental Health
Program form 1) Place Interpretation and Recommendations/Actions taken.

2.19.5 Tuberculosis – Put the totals for the quarter per indicator and place Interpretation and
2.19.6 Leprosy – Put the totals for the quarter per indicator and place Interpretation and

2.19.7 Malaria ‐ Put the totals for the quarter per indicator and place Interpretation and
2.19.8 Schistosomiasis ‐ Put the totals for the quarter per indicator and place Interpretation and

2.19.9 Filariasis ‐ Put the totals for the quarter per indicator and place Interpretation and

2.21 THE QUARTERLY CONSOLIDATION REPORT OF MORBIDITY DISEASES (Q2):
The Quarterly Report of Morbidity Diseases contains a list of all diseases by age and gender. It summarizes
quarterly of diseases that are reported in the municipality/city for which the PHN is responsible, then forwards
this report to the Provincial FHSIS Coordinator at the PHO every third week of the first month of the
succeeding quarter for provincial consolidation.

Heading ‐ Fill the Year for which the report is being prepared. Write the full name of the
Municipality/City and Province and the quarter.

Filling up the report

Write in the space provided the disease name, the quarter total number of males (M) and females (F)
for the corresponding age grouping reported for the particular disease. Data for the quarterly
consolidation comes from the Monthly Report of the Midwife and data found in the RHU.

105
2.20.1 Maternal Care
FHSIS ver 2012
FHSIS REPORT for the QUARTER_________________ YEAR: ______________

logo Municipality/City Name: __________________________________________
Province: ___________________Projected Population of the Year: ____________
- MATERNAL CARE -
Elig Recommendation/
Indicators No. % Interpretation
Pop. Actions Taken
Col. 1 Col.2 Col. 3 Col.4 Col. 5 Col. 6
Pregnant women with 4 or more prenatal visits ♣
Pregnant women given 2 doses of Tetanus Toxoid♣
Pregnant Women given TT2plus ♣

Pregnant women given complete iron with folic acid
supplementation♣
Post partum women with at least 2 post-partum visits♥
Post partum women given complete iron

supplementation♥
Proportion of Post partum women given Vitamin A
supplementation♥
Proportion Postpartum women initiated breastfeeding
within 1 hour after giving birth♥
Women 10-49 years old given Iron supplementation♥
Eligible Population: ♣ TP x 2.7%
106
2.20.2 Family Planning FHSIS v. 2012 - Q Form (page 2 of 8)
- FAMILY PLANNING-
Acceptors New
Current Current CPR =
Acceptors Recommendations/
Indicators User (Beg. Dropout Users End (Col. 5/TP Interpretation
New Other of the Actions Taken
of Quarter) of Quarter x 12.325%)
(end of (end of Quarter
Qtr) Qtr)
Col. 1 Col.2 Col.3 Col.4 Col.5 Col.6 Col.7 Col.8 Col.9
a. Female Ster/BTL
b. Male Ster/Vasectomy
c. Pills
d. IUD
e. Injectables (DMPA/CIC)
f. NFP-CM
g. NFP-BBT
h. NFP-STM
i. NFP-SDM
j. NFP-LAM
k. Condom
l. Implants
107
2.20.3 Child Care FHSIS v. 2012 - Q Form (page 3 of 8)
- CHILD CARE -
Elig. Number Recommendation/
Indicators % Interpretation
Pop. Male Female Total Actions Taken
Col. 1 Col.2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7 Col. 8
Infants given BCG☻
w/in 24 hours
Infants given Hepatitis B1☻
> 24 hours
1
Infants given PENTA☻ 2
3
1
Proportion of Infants given OPV☻ 2
3
MCV1 (AMV)
Proportion of Infants given MCV☻
MCV2 (MMR)
1
Proportion of Infants given ROTA☻
2
1
Proportion of Infants given PCV☻ 2
3
Proportion of Fully Immunized Child (0-11 mos)☻
Proportion of Completely Immunized Child (12-23 mos)☻
Total Livebirths
Proportion of Child Protected at Birth (CPAB)♣
Proportion of Infants age 6 mos. seen
Proportion of Infants exclusively breastfed until 6th month old☻
Infants given complimentary food from 6-8 months♣
Proportion of Infants for newborn screening
- referred
- done
Eligible Population: ☻TP x 2.7% ♣Total Livebirths
108
FHSIS v. 2012 - Q Form (page 4 of 8)
- CHILD CARE -
Indicators Pop. Male Femal Total % Interpretation Actions Taken
Infant 6-11 months old received Vitamin A ☼
Children 12-59 months old received Vitamin A ♠
Infant 6-11 months old received Iron
Children 12-59 months old received Iron
Infant 6-11 months old received MNP ☼
Children 12-23 months old received MNP ©
Sick Children 6-11 mos. seen
Sick Children 6-11 mos. received Vit. A♣
Sick Children 12-59 mos. seen
Sick Children 12-59 mos. received Vit.A♣♣
Children 12-59 mos. old given de-worming tablet
Infant 2-5 mos.w/ low birthweight seen
Infant 2-5 mos.w/ low birthweight received full dose iron♥
Anemic Children 6-11 months old seen
Anemic Child. 6-11 months received iron ●
Anemic Children 12-59 months old seen
Anemic Child. 12-59 months received iron ▲
Diarrhea cases 0-59 months old seen
Diarrhea cases 0-59 mos old received ORS☻
Diarrhea 0-59 mos old received ORS/ORT w/ zinc☻
Pneumonia cases 0-59 mos. old seen
Pneumonia cases 0-59 mos. old completed Tx♦
Eligible Pop: ☼TP x 1.35% ♠TP x 10.8% ♣Sick Child 6-11 mos. seen ♣♣Sick Child 12-59 mos. seen ● Anemic Children 6-11 mos. seen
♥Infant 2-5 mos.w/LBW seen ▲ Anemic Child 12-59 mos. old seen ☻No.Diarrhea cases 0-59 mos old seen ♦No.Pneumonia cases 0-59 mos seen
109
2.20.4 Dental Care FHSIS v. 2012 - Q Form (page 5 of 8)
- DENTAL CARE -
Indicators % Interpretation Actions Taken
Pop. Male Female Total
Orally Fit Children 12-71 months
old♠
Children 12-71 months old
provided with BOHC♠
Adolescent & Youth(10-24 years)
given BOHC☻
Pregnant women provided
with BOHC♥
Older Person 60 yrs old & above
provided with BOHC♣
Eligible Population: ♠TP x 13.5% ☻TP x 30% ♥TP x 2.7% ♣TP x 6.9%
110
2.20.5 Disease Control FHSIS v. 2012- Q Form (page 6 of 8 )
- DISEASE CONTROL -
Number Recommendation/
TUBERCULOSIS Interpretation
Male Female Total Actions Taken
Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6
1. TB symptomatics who underwent DSSM
2. Smear positive discovered and identified
3. New smear positive cases initiated tx and registered

4. New smear (+) cases cured
5. Smear(+) retreatment cases cured
6. Smear (+) retreatment cases initiated tx and registered
● Relapse
7. No, of Smear (+) retreatment cured
● Relapse
8.. Total No. of TB cases (all forms) initiated treatment

10. Case Detection Rate
LEPROSY Rate Interpretation
Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7
1. Total Population
2. Total No. of Leprosy cases (undergoing Treatment)
Leprosy cases
► < 15 yo
4. No of Leprosy Cases cured
Denominator  TP x 0.00275 (estimated TB All Forms)
111
FHSIS v. 2012- Q Form (page 7 of 8)
- DISEASE CONTROL -
MALARIA Number Recommendation/
Rate Interpretation
(Endemic Areas) Male Female Total Actions Taken
Total Population
Population at risk ♦
Morbidity Annual Parasite
Rate ♣ Incidence
Annual Parasite Incidence
Confirmed Malaria Cases

By age group
● < 5 yo
● > =5 yo
By pregnancy
●Pregnant ☻
By species
● P.falciparum ☻
● P. vivax ☻
● P.ovale ☻
● P.malariae ☻
By Method
● Slide☻
● RDT☻
Total no. of LLIN given♦

Mortality Case Fatality
Rate ♪ Ratio
Total no. of Malaria Deaths♪
Denominator: ♣Morbidity Rate=TP; Annual Parasite Incidence=Endemic Pop >5 & <5 yo Population
☻Total Confirmed Malaria Case ♦Population at risk ♪Mortality rate=TP; Case Fatality Ratio=Total Malaria Cases
112
FHSIS v. 2012 - Q Form (page 8 of 8)
- DISEASE CONTROL -
SCHISTOSOMIASIS Number Recommendation/
Rate Interpretation
(endemic areas) Male Female Total Actions Taken
Symptomatic cases
Case examined ♥
Positive Cases ☻
● Low intensity ♣
● Medium intensity ♣
● High intensity ♣
Cases treated ♣
Complicated Cases ♣
Complicated Cases referred ♣
FILARIASIS Number Recommendation/
Rate Interpretation
(endemic areas) Male Female Total Actions Taken
1.No. Cases with hydrocele,

lymphedema, Elephantiasis, Chyluria ☻
2. Clinical Rate
4. No of Cases examined found Positive
for MF ☻
5. Average MFD ☻
6. Eligible population given MDA (94.6%
of TP) ♠
Denominator for Schistosomiasis: ☻Case examined ♣ Positive Schistosomiasis cases ♥ Symptomatic cases
♠ Total population given MDA
113
2.21.1 Form 1 Notifiable Diseases FHSIS v. 2012 - Qmorbid (page 2 of 2)
. FHSIS v.2012
FHSIS QUARTERLY REPORT for: Year:

Municipality/City of:
Province
For submission to the PHO
OF ICD Code Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & over TOTAL

Influenza J11
Acute Hemorrhagic Fever Syndrome (Dengue) A91
Pneumonia J18.9
Cholera A00
Diphtheria A36
Filarisis B74
Leprosy A30
Leptospirosis A27
Malaria B50-B54
Measles B05
Meningococcemia A39
Rabies A82
Schistosomiasis B65
Syphilis A50-A53
Gonorrhea A54.9
Genital Ulcer N48.5, N76.5, N76.6
114
2.21.2 Form 2 Other Diseases FHSIS v. 2012 - Qmorbid (page 1 of 2)
.
FHSIS QUARTERLY REPORT for: Year:
ProvInce
ICD 10 Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 & above TOTAL
DISEASE
CODE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
115
FHSIS – DIC – 2012‐01
2.22 THE ANNUAL FORMS :

2.22.1 Annual BHS Report (A‐BHS)

The Annual BHS Report Form contains basic information about the BHS which are submitted only once year. It
consists of data categorized under demographic, environmental and natality. The midwife in the BHS fills‐up
the form and submits to the RHU/MHC for consolidation.

Heading
Fill in the required information for the Year, complete name of the BHS, municipality/city and the
province.

Filling up the form.
For Demographic Profile, write the population, number of barangays and households. The indicators
are the same with those found in the Annual Form 1 and same definitions must be followed.

2.22.2 Annual Form 1 – Vital Statistics Report (A1‐RHU)

The Annual Form contains basic information about the municipality or city which is being submitted only once
a year. It consists of data categorized under demographic, environmental, natality and mortality. The nurse in
the RHU/MHC fills up the form and submits to the PHO for computer processing.

Heading
Fill in the required information for the Year, complete name of the RHU and province.

Filling‐up the form
The Annual Form consists of the program indicators listed in the first column, followed by the
number, the percentage accomplishment or ratio/rate, the interpretation or analysis of data and the
recommendations or action taken by your area. To facilitate computation of rates/ratios,
denominators for some indicators are listed below.

2.22.2.1 Demographic Information
 No. of Barangays – Write on the space provided the actual number of barangays within the
municipality/city.

 No. of BHSs – Write on the space provided the actual number of barangay health stations. A BHS
can be considered a reporting unit if the following conditions are satisfied:

a. It renders/delivers health services to a defined catchment area which may be composed
of one or more barangays.
b. A midwife renders regular service to the area. In case where the midwife of the area is
in prolonged leave of absence or resigned but a replacement is expected, the BHS
remains a reporting unit. The reports are expected to be submitted by the nurse or
midwife(s) who took over the servicing of the area.
c. Health services may be provided from any physical structure designated for the
purpose i.e. a BHS building, a barangay hall or a place of residence.
d. The catchment area served is not a service area of any RHU. For instance, Poblacion in
most cases is the catchment area served by the RHU. Thus, the Poblacion BHS cannot be
considered a reporting unit. The reports of this BHS should be prepared and submitted
by the RHU.
e. It should not include satellite BHS which are visited by the midwife but part of the
catchment of the “mother” BHS.

116
FHSIS – DIC – 2012‐01
 No. of Health Workers in LGU – This includes nationally paid public health workers and those hired
by the local government. Write on the space provided the total number of doctors, dentists,
nurses, midwives, nutritionists, medical technologists, engineers, sanitary inspectors and
active BHWs.

NOTE: Hospital personnel are not included in this indicator.

2.22.2.2 ENVIRONMENTAL

 No. of Households (HH) – Write on the space provided the actual number of households in the
municipality. The data should be based on actual household survey within the locality.

 Households with access to improved or safe water supply – Write on the space provided the
number of households covered by or have access to the following types of drinking water
sources that conforms to the Philippine National Standards for Drinking Water (PNSDW)
(i.e., free from bacterial, chemical, physical and other contaminants):

Level I (Point Source) – A protected well (shallow and deep well) improved dug well,
developed spring, rainwater cistern with an outlet but without distribution system.

Level II (Communal Faucet System or Standpost) – Refers to a system composed of a source,
a reservoir, a piped distribution network, and a communal faucet located not more than 25
meters from the farthest house. It is generally suitable for rural and urban areas where
houses are clustered densely enough to justify a simple piped water system. Note: For
reporting purposes Level II system may also include a communal faucet connected to Level III
where group of households get their water supply.

Level III (Waterworks System) – A system with a source, transmission pipes, a reservoir,
and a piped distribution network for household taps. It is generally suited for densely‐
populated areas. Examples of these are MWSS and water districts with individual household
connections. Note: For reporting purposes of Level III system may also include a Level I
system with piped distribution for household tap serving individual or group of housing
dwellings such as apartments or condominiums.

 Households with sanitary toilet facilities – Write on the space provided the total number of
households with sanitary toilets. This refers to households with flush toilets connected to
septic tank and/or sewerage system or any other approved treatment system, sanitary pit
latrine or ventilated improved pit latrine.

 Households with satisfactory disposal of solid waste – Write on the space provided the total
number of households with garbage disposal through composting, burying, city/municipal
system storage, collection and disposal.

 Households with complete basic sanitation facilities – Write on the space provided the total
number of households which satisfy the presence of the following basic sanitation elements,
namely: access to safe water, availability of a sanitary toilet and satisfactory system of
garbage disposal.

 Food Establishments – Write on the space provided the total number of food establishments
which includes restaurants, sari‐sari stores, canteens, coffee shops, carinderia, refreshment
parlors, bakeries, water refilling stations, food manufacturing, bottling, dairy and canning
establishments.

 Food Establishments with Sanitary Permit – Write on the space provided the total number of food
establishments with sanitary permit.
117
FHSIS – DIC – 2012‐01

 Food Handlers – Write on the space provided the total number of food handlers employed in food
establishments

 Food Handlers with Health Certificates – Write on the space provided the total number of food
handlers with health certificates.

2.22.2.3 NATALITY
 No. of Pregnancies‐Write on the space provided the total number of pregnancies.

Pregnancy by outcome

Livebirths ‐ write on the space provided the total number of live births

Fetal Deaths ‐ write on the space provided the total number of fetal death

Abortion ‐ write on the space provided the total number of abortion

 No. of deliveries by type

Normal Spontaneous Delivery (NSD) ‐ write on the space provided the total number of NSD

Others ‐ write on the space provided the total number deliveries other than NSD

 Weight at birth

2,500 grams and greater – Write on the space provided the total number of live births with
weights equal to or greater than 2,500 grams.

Less than 2,500 grams – Write on the space provided the total number of live births with
weights less than 2,500 grams.

Not known – Write on the space provided the total number of live births
whose weights at birth are not known.

Deliveries Attended by:

Doctors – Write on the space provided the number of deliveries by doctors.

Nurses – Write on the space provided the number of deliveries attended by nurses.

Midwives – Write on the space provided the number of deliveries attended by midwives.

Trained Hilot/TBA – Write on the space provided the number of births attended by trained
hilot or health worker not mentioned above.

Others – Write on the space provided the number of births attended by those other than
the above mentioned.

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FHSIS – DIC – 2012‐01
 No. of livebirths

Column 2(Male) – write on the space provided the total number of males were born alive in
the Health Center from TCL of prenatal and LCR.

Column 3(Female) – write on the space provided the total number of females who were
born alive in the Health Center from TCL of prenatal and LCR.

Column 4(Total) – write on the space provided the total number of
females and males who were born alive in the Health Center from TCL of prenatal and LCR.

Column 5(Percent) – write on the space provided the percent of the total number of females
and males who were born alive in the Health Center from TCL of prenatal and LCR.

 Deliveries by Place:

Health Facility – Hospital, RHU or Lying‐in (including BEMONC, CEMONC) – write on the
space provided the total number of live births that were delivered in government or private
hospitals, RHU or Lying‐in (including BEMONC, CEMONC).

Non‐institutional Delivery (NID) – write on the space provided the total number of live births
that were delivered at home or other than health facility.

2.22.2.4 MORTALITY

 Deaths by sex:
Male – write on the space provided the total number of male deaths
Female – write on the space provided the total number of female deaths

 Maternal Mortality – write on the space provided the total number of pregnant women who died
due to causes related to pregnancy, childbirth and puerperium.

 Infant Mortality – write on the space provided the total number of infant deaths.

 Under Five Mortality – write on the space provided the total number of deaths among children
under five years of age.

 Fetal Deaths – write on the space provided the total number of fetus who reaches the age of
viability (20weeks+), and a weight of more than 500 grams delivered dead or died inside the
womb.

 Perinatal Deaths – write on the space provided the total number of fetus who died from 22ndweek
of gestation (the time when birth weight is normally 500mg) and ends 7 completed days
after birth.

 Neonatal Mortality – write on the space provided the total number of deaths between births up to
28 days of age.

 Deaths due to Neonatal Tetanus – write on the space provided the total number of deaths 3 to 28
days of age due to tetanus neonatorum.

119
FHSIS – DIC – 2012‐01
Annual Form 2 – Morbidity Disease Report

This report is prepared by the PHN as the annual consolidation of the monthly and quarterly
morbidity disease reports from the BHSs and the RHUs. The Source of this report is the Summary Table. The
report consists of all reported causes of morbidity diseases with age and sex breakdown, and submitted to the
PHO.

Annual Form 3 – Mortality Report

This report is the annual consolidation of all deaths occurred in your area. The Source of this report is
the Summary Table. The PHN who prepares this report breaks down the number reported in each disease by
age and gender.

120
FHSIS version 2012
FHSIS BHS ANNUAL Report for the year __________________

Name of BRGY and BHS ______________________________
Municipality/City of______________Province_______________
VITAL STATISTICS REPORT
DEMOGRAPHIC
Population No. of Households
Barangay No. of BHS
ENVIRONMENTAL No. %
Households with access to improved or safe water supply
● Level I (Point Source)
● Level II (Communal Faucet System or Standpost)
● Level III (Waterworks System)
Households with sanitary toilet facilities
Households with satisfactory disposal of solid waste
Households with complete basic sanitation facilities
Food Establishments
Food Establishments with sanitary permit
Food Handlers
Food Handlers with health certificate
Salt Samples Tested
Salt Samples Tested (+) for iodine
NATALITY
No. of Livebirths Birthweight Male Female Total
● No. of Male 2500 grams & greater
● No. of Female Less than 2500 grams
Deliveries Attended by Not Known
Male Female Total Total
Doctors
Nurses Pregnancy Outcome Male Female Total
Midwives Livebirths
Hilot/TBA Fetal Deaths
Others Abortion
Deliveries by Type and Place Prepared by:
NID Health
Type
Home Others Faciltiy Noted/Approved by:
Normal
Others Date Prepared:
121
2.22.3.2 Demographic Profile (A1-RHU)
FHSIS version 2012
FHSIS ANNUAL REPORT FOR YEAR: ______________________________________

Municipality/City Name: ___________________________________________________
No. of Health Centers _____________________
Province: _____________________Projected Population of the Year: _____________
- DEMOGRAPHIC PROFILE -
Number Ratio to Recommendation/
Indicators Interpretation
Male Female Total Pop. Actions Taken
Barangays
Barangay Health Stations
Health Centers
Households
Physicians/Doctors
Dentist
Nurses
Midwives
Medical Technologists
Sanitary Engineers
Sanitation Inspectors
Nutritionist
Active Barangay Health Workers
122
2.22.3.3 Environmental FHSIS v. 2012 - A Form (page 2 of 5 )
- ENVIRONMENTAL -
Indicators No. % Interpretation Recommendation/
Actions Taken
Col. 1 Col 2 Col. 3 Col. 4 Col. 5
Total number of Households (HH)

HH w/ access to improved
water supply♣
- Level I♣
- Level II♣
- Level III♣
HH w/ sanitary toilet facilities♣
HH w/satisfactory disposal of solid waste♣
HH w/complete basic sanitation facilities♣
Food Establishment
Food Establishment w/Sanitary Permit♥
Food Handlers
Food Handlers w/Health Certificate☻
Salt Samples Tested
Salt Samples Tested (+) for Iodine

Denominator: ♣No. Households ♥No.Food Establishments ☻No.Food Handlers
123
2.22.3.4 Natality - Livebirths FHSIS v. 2012- A Form (page 3 of 5)
NATALITY - LIVEBIRTHS
Indicators Number % Interpretation Recommendation/
Col. 1 Col 2 Col 3 Col 4 Col. 5 Col. 6 Col. 7
No. of Pregnancies
Pregnancies by outcome
Livebirths (LB)
Fetal Death
Abortion
No. of Deliveries
NSD
Operative
LB w/weights 2500 grams & greater☻
LB w/weights less than 2500 grams☻
LB - Not known weight☻
LB delivered by doctors☻
LB delivered by nurses☻
LB delivered by midwives☻
LB delivered by hilot/TBA☻
LB delivered by others☻
Denominator: ☻Livebirths
124
2.22.3.5 Natality - Deliveries FHSIS v. 2012- A Form (page 4 of 5)
- NATALITY - DELIVERIES -
Indicators No. % Interpretation Recommendation/
Actions Taken
Col. 1 Col 2 Col. 3 Col. 4 Col. 5
Total No. of Pregnancies♣

Outcome of Pregnancy♣
• Live Births
• Fetal death
• Abortion
Normal Deliveries ♣
● Deliveries at Home♥
● Deliveries at Health Facility♥
● Deliveries - Other Place♥
Operative Deliveries ♣
● Deliveries at Health Facility♠
● Deliveries-Other Place♠
Denominator: ☻Livebirths ♣Pregnancies ♥Normal Deliveries ♠Other Type of Deliveries
125
2.22.3.6 Mortality FHSIS v. 2012 - A Form (page 5 of 5)
- MORTALITY -
Indicators Rate Interpretation
Col. 1 Col 2 Col 3 Col 4 Col. 5 Col. 6 Col. 7
Deaths♣
Maternal Deaths☻
Perinatal Deaths☻
Fetal Deaths☻
Neonatal Deaths☻
Infant Deaths☻
Deaths among children Under 5 yrs old☻
Deaths due to Neonatal Tetanus☻
Denominator: ♣ Population ☻Livebirths
126
. FHSIS v.2008
FHSIS ANNUAL REPORT for YEAR:

ProvInce
ICD 10 Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 & above TOTAL
DISEASE
CODE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
127
2.22.3.8 Mortality Report (A3-RHU)
. FHSIS v.2012
FHSIS ANNUAL REPORT for YEAR:

ProvInce
MORTALITY REPORT
Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 & above TOTAL

DISEASE
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
128
Chapter Three
___________________
FHSIS VER. 2012

METADATA

FHSIS INDICATOR METADATA

FHSIS v. 2012

Indicator Metadata 3.1 DEMOGRAPHIC INFORMATION

_____________________________________________________________________________________________________________________________________________________________

Source of Frequency of
Indicator Definition Formula Target Use and Limitation
Data Reporting
1. Population The total number of inhabitants constituting a particular No. of Population NSO Annual In statistics the entire
race, class, or group in a specified area. aggregation of items from
Disaggregation: Projected which samples can be drawn;
 Region Population "it is an estimate of the mean
 Province of the population"
 Cities
2. No. of Main Main Health Center refers to an expanded rural health
Health Centers unit, usually located in a strategic area where there are no
hospitals. It has one or two lying‐in beds and may have a
larger personnel compliment than a regular RHU

3. No. of Barangays The total number of barangays within the No. of Barangays RHU Annual
municipality/city.
FHSIS
Disaggregation: Definition of Terms:
 Region A barangay (Tagalog: baranggay), also known by its
 Province former name, the barrio, is the smallest local government
 Cities unit in the Philippines and is the native Filipino term for a
village, district or ward. Municipalities and cities are
composed of barangays.

4. No. of Barangay The total number of barangay health stations within the No. of BHS RHUs Annual
Health Stations municipality/city. Reports
Definition of Terms:
Barangay Health Stations refers to the first facility in the
130
Data Reporting
Public Health Systems. It is manned by a cadre of
volunteer BHWs under the supervision of the RHM. The
MHO normally conducts diagnostic consultations and
gives prescriptions and referrals on a regular basis in the
BHS. The BHWs are trained in preventive health care with
a strong emphasis on maternal and child care, family
planning and reproductive health, nutrition and
sanitation, as well as, prevention and care of common
diseases.

5. No. of The total number of households in the municipality/city Numerator: No. of House to Annual
Households Households house
Definition of Terms: Survey
Disaggregation: A household (NSO definition) is a social unit consisting of a
 Region person living alone or a group of persons who: Note: In the absence of
 Province 1) sleep in the same housing unit; and actual HH survey, use the
 Cities 2) have a common arrangement for the preparation and suggested formula below
consumption of food
Denominator: Total
Population divided by 6
6. Ratio of Public This includes nationally paid health workers and those Numerator: Total Population Annual
Health Personnel hired by the local government. Health Manpower includes of a given area
Doctors, Dentists, Nurses, Midwives, Medical
Technologists, Sanitation Engineers, Sanitation Inspectors Denominator: Total No. of
and Active BHWs. Health Manpower

Definition of Terms:

Physician/Doctors – all graduates of any faculty or school Physician
of medicine, actually working in the country in any 1:20,000
medical field (practice, teaching, administration, research,
laboratory, etc.)

Municipal Health Officer – He/She heads the decentralized
health services at the municipal level and serves as
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Data Reporting
administrator of the rural health unit, the primary health
facility in the area. As a community physician, he / she
conducts epidemiological studies / investigation,
formulates health education campaigns on disease
prevention, and prepares and implements control
measures or rehabilitation plans. He / She also serve as
the medico‐legal officer. As health administrator, his/her
functions include the preparation of the municipal health
plan and budget; monitoring the implementation of basic
health services, and management of the RHU staff.

Dentists – are professional people qualified to perform Dentist
procedures in the Oral Cavity in order to provide 1:50,000
preventive, curative and rehabilitation services.

Nurses – all persons who have completed a program of Nurse
basic nursing education and are qualified and registered 1:20,000
or authorized to provide responsible and competent
service for the promotion of health, prevention of illness,
care of the sick, and rehabilitation, and are actually
working in the country. The Public Health Nurse (PHN) ‐
supervises and guides all rural health midwives (RHMs) in
the municipality. He / She handle the health records of the
community including data on morbidity and mortality
cases, program accomplishments, etc. The PHN also
prepares monthly and quarterly reports to the MHO.

Midwives – persons who have completed a program of Midwife
midwifery education, and have acquired the requisite 1:5,000
qualifications to be registered and / or legally licensed to
practice midwifery, and are actually working in the
country. The Rural Health Midwife (RHM) manages the
BHS and supervises and trains the BHW in the community.
He / She provides midwifery services and execute heath
care to women of reproductive age including family
planning counseling and services, He / She conducts
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Data Reporting
patient assessment and diagnosis for referral / further
management; performs health IEC activities, organizes the
community, and facilitates Barangay health planning and
other community health services.

Medical Technologist – is a duly licensed health care
professional who works on clinical laboratories and
performs diagnostic analytic tests on human body fluids
such as flood, urine, sputum, stool, cerebrospinal fluid
(CSF), peritoneal fluid, pericardial fluid, and synovial fluid,
as well as other specimens. Medical Technologists work in
clinical laboratories at hospitals, doctor’s office, reference
labs, and within the biotechnology industry.

Sanitary Engineers – a person duly registered with the RSI
Board of Examiners for Sanitary Engineers (RA1364) and 1:20,000
who heads the sanitation division or section or unit of the
province /city / municipal health office or employed with
the Department of Health or its regional field health units.

Sanitation Inspectors – a government official or personnel
employed by national, provincial, city or municipal
government who enforces sanitary rules, laws and
regulations and implements environmental sanitation
activities under the supervision of the province /city /
municipal health officer / sanitary engineers. Rural
Sanitation inspectors (RSI), functions are directed towards
ensuring a healthy municipality. This entails advocacy,
monitoring, and regulatory activities such as, inspection of
water supply and unhygienic household conditions.

Nutritionist / Dietician – is a health specialist that devotes Nutritionist
professional activity to food and nutritional science, 1:20,000
preventive nutrition, diseases related to nutrient
deficiencies, and the use of nutrient manipulation to

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Data Reporting
enhance the clinical response to human diseases. They can
also advise people on dietary matters relating to health,
well‐being and optimal nutrition.
BHW
Barangay Health Worker (BHW) – an indigenous member 1:20HHs
of the community that acts as a link of the health system
in the community.

134

3.2 N A T A L I T Y

_____________________________________________________________________________________________________________________________________________________________

Data Reporting
1. Crude Birth Rate The ratio of the total number of live births in a given Numerator: Total number of LCR and Annual
population during a year to the mid‐year population Live births TCL
Disaggregation: during a given period expressed per 1, 000 population. (ensure
 Live births by Sometimes it is referred to simply as the birth rate and Denominator: Total mechanism
Sex also live birth rate Population x 1,000 for no
double
Definition of Terms: reporting)
Live birth is the complete expulsion or extraction from its
mother of a product of conception, irrespective of the
duration of the pregnancy, which, after such separation,
breathes or shows any other evidence of life, such as
beating of the heart, pulsation of the umbilical cord, or
definite movement of voluntary muscles, whether or not
the umbilical cord has been cut or the placenta is
attached; each product of such a birth is considered live
born.

2. Proportion of This refers to babies born alive who weigh 2500 grams and Numerator: No. of livebirths LCR and Annual The rate of LBW is a rough
Live births greater, less than 2500 grams and unknown weight. by weight TCL summary measure of many
● 2500 grams & greater (ensure factors, including maternal,
Disaggregation: Definition of Terms: ● less than 2500 grams mechanism nutrition, lifestyle (e.g. alcohol,
 Live births by ● not known for no tobacco and drug use) and
weight Birth weight is the first weight of the infant obtained after double other exposures in pregnancy
birth. For live births, birth weight should preferably be Denominator: Total No. of reporting) (e.g. infectious diseases and
measured within the first hour of life before significant Live births attitude). LBW is strongly
postnatal weight loss has occurred. associated with a range of
adverse health outcomes, such
as perinatal mortality and
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Data Reporting
2500 grams and greater – live births with weights equal to morbidity, disability and
or greater than 2500 grams. disease in later life, but is not
necessarily part of the cause.
Less than 2500 grams – live births with weights less than LBW is a strong predictor of an
2500 grams individual baby’s survival. The
lower the birth weight the
Not known – live births whose weights at birth are not higher the risk of death.
known.
3. Proportion of This refers to births attended by skilled health personnel. Numerator: Total No. of 90% (NOH LCR and Annual The indicator helps program
births attended live births attended by skilled 2016) TCL management at district,
by skilled health Definition of terms: health personnel (ensure national and international
personnel Skilled health personnel (sometimes referred to as skilled mechanism levels by indicating whether
attendant) is defined as an accredited health professional Denominator: Total No. of for no safe motherhood program are
Disaggregation: such as midwife, doctor or nurse – who has been educated Livebirths double on target in the availability and
 Live births by and trained to proficiency in the skills needed to manage reporting) utilization of professional
Birth Attendant normal (uncomplicated) pregnancies, childbirth and the assistance at delivery. In
(doctor, nurse, immediate postnatal period, and in the identification, addition, the proportion of
midwife) management and referral of complications in women and births attended by skilled
newborns. This definition excludes traditional birth personnel is a measure of the
attendants whether trained or not, from the category of health system’s functioning
skilled health workers. and potential to provide
adequate coverage for
MDG indicator of Proportion (%) of births attended by deliveries. On the other hand,
skilled health personnel: (G5.T6.I17): Percentage of births this indicator does not take
attended by skilled health personnel to total number of account of the type and quality
live births in a given year. Skilled health personnel refer of care.
exclusively to those health personnel (for example,
doctors, nurses, midwives) who have been trained to
proficiency in the skills necessary to manage normal
deliveries and diagnose or refer obstetric complications.
Traditional birth attendants trained or untrained are not
included in this category. (WHO)

4. Proportion of This refers to deliveries by place. Numerator: 90% of LCR and Annual Proportion of births delivered
deliveries by place ● No. of deliveries at deliveries TCL in a facility. It is a measure of
136
Data Reporting
Health facility: hospitals, RHUs, lying‐ins health facility in a (ensure the health systems’
Health Facility or ● No. of non‐institutional health mechanism functionality and potential to
Non‐institutional Non‐institutional delivery includes: home, transit and any deliveries facility for no provide adequate coverage for
Delivery delivery other than health facility Denominator: Total No. of (NOH double deliveries.
Deliveries 2016) reporting)
5. Proportion of This refers to deliveries by type. Numerator: LCR and Annual While this is a good measure of
deliveries by type ● No. of Normal Deliveries TCL risk factor on pregnancy and
Definition of terms: at home/health facility/ (ensure child birth, it does not
Disaggregation: others mechanism adequately measure or predict
 Type Deliveries by Type: for no the outcome of the pregnancy
● No. of Operative Type of double or child birth per se. The new
Normal – refers to deliveries by normal spontaneous Deliveries at health facility reporting) paradigm shift is “all pregnancy
delivery (NSD) is at risk for complications”.
Operative – refers to deliveries delivered other than NSD Denominator: Total No. of
Deliveries
6. Proportion of This refers to pregnancy by outcome. LCR and
pregnancy by TCL
outcome Live birth ‐ is the complete expulsion or extraction from its (ensure
mother of a product of conception, irrespective of the mechanism
duration of the pregnancy, which, after such separation, for no
breathes or shows any other evidence of life, such as double
beating of the heart, pulsation of the umbilical cord, or reporting)
definite movement of voluntary muscles, whether or not
the umbilical cord has been cut or the placenta is
attached; each product of such a birth is considered live
born
 Term ‐ 37th to 40th week
 Premature – 24th to 36th week
 LBW (low birth weight) – weight at birth is less
than 2.5 kilograms
Fetal Death ‐ death of the fetus prior to the complete
expulsion from the mother; the death is indicated by the
fact that after separation, the fetus does not breath or
show any evidence of life such as beating of the heart,

137
Data Reporting
pulsation of the umbilical cord or definite movement of
voluntary muscles. (20 weeks and above)

Abortion ‐ is the termination of a pregnancy before the
fetus has attained viability, i.e. become capable of
independent extrauterine life

138
3.3 M O R T A L I T Y

___________________________________________________________________________________________________________________________________________________

Data Reporting
1. Mortality Rate An estimate of the proportion of a population that dies Numerator: No. of persons LCR and Annual
during a specified period. died during the period TCL, RHU
Disaggregation: log book
 Sex Denominator: Total
Population x 1,000

2. Maternal The ratio of the number of maternal deaths per 100,000 Numerator: No. of Maternal 52 per LCR and Annual The maternal mortality ratio is
Mortality Ratio live births per year. Deaths 100,000 TCL, RHU the most widely used measure
(MMR) LB log book of maternal death. It measures
Definition of terms: Denominator: Total No. of obstetric risk – in other words,
Live births x 100,000 the risk of a woman dying once
Maternal death is the death of woman while pregnant or she is pregnant. It does not
within 42 days of termination of pregnancy, irrespective of therefore take into account the
the duration and the site of the pregnancy, from any cause risk of being pregnant (i.e.
related to or aggravated by the pregnancy or its fertility) in a population, which
management, but not from accidental or incidental causes. is measured by the maternal
mortality rate or the lifetime
risk.
3. Neonatal Any neonatal death between births up to 28 days of age Numerator: No of neonatal 10 Deaths LCR and Annual
mortality rate per 1000 Livebirths deaths per 1,000 TCL, RHU
LB (NOH log book
Denominator: Total No. of 2016)
live births x 1,000

4. Infant Mortality The ratio of the number of deaths among infants (below Numerator: No. of infant 17 deaths LCR and Annual Measures the risk of dying
Rate (IMR) one year of age) per 1,000 Livebirths deaths (below one year of per 1,000 TCL during the first year of life. It is
age) LB a good index of the general
Definition of terms: (NOH health condition of a
Denominator: Total No. of 2016) community since it reflects the
Infant Mortality Rate: Probability of dying between birth live births x 1,000 changes in the environmental
139
Data Reporting
and exactly one year of age, expressed per 1,000 live births and medical condition of a
community.

5. Under Five The probability of dying between birth and exactly five Numerator: No. of deaths 25.5 LCR and Annual
Mortality Ratio years of age, expressed per 1,000 live births among children under 5 deaths TCL
years of age per 1,000
LB (NOH
Denominator: Total No. of 2016)
live births x 1,000
5. Perinatal Is the number of deaths of fetuses weighing at least 500 g Numerator: Number of Fetal 18 LCR and Annual The perinatal mortality
Mortality Rate (or, when birth weight is unavailable, after 22 completed Deaths of 22 or more weeks Perinatal TCL, RHU indicator plays a major role in
weeks of gestation or with a crown–heel length of 25 cm or gestation + Number of Deaths log book providing the information
more), PLUS the number of early neonatal deaths, per Newborns dying under 7 per 1,000 needed to improve the health
1000 livebirths. Because of the different denominators in days of age) LB (NOH status of pregnant women, new
each component, this is not necessarily equal to the sum of 2016) mothers and newborns. That
the fetal death rate and the early neonatal mortality rate. Denominator: Number of information allows decision‐
Live Births + Fetal Deaths of makers to identify problems,
Fetal Death Rate Number of fetal deaths per 1000 Livebirths. Fetal deaths 22 or more weeks gestation track temporal (related to time)
refers to those number of deaths of fetuses weighing at X 1,000 and geographical trends
least 500 g (or, when birth weight is unavailable, after 22 (related to place) and
completed weeks of gestation or with a crown–heel length disparities and assesses
of 25 cm or more) changes in the public health
policy and practice. This is the
Early neonatal Number of neonatal deaths from 0‐6 days of life most sensitive measure for
deaths maternal health and newborn
care.

7. Neonatal Tetanus Any neonatal death between 3 and 28 days of age in which Numerator: No. of deaths Less than LCR and Annual
Mortality Rate the cause of death is unknown or due to neonatal tetanus. due to neonatal tetanus 1 case TCL, RHU
per 1,000 log book
Denominator: Total No. of live births
live births x 1,000

140

3.4 ENVIRONMENTAL HEALTH

_____________________________________________________________________________________________________________________________________________________________

Data Reporting
1. Proportion of Refers to households covered by or have access to the Numerator : Total No. of 94 by Annual
Households with following improved types of drinking water sources Households with access 2016
access to improved to improved or safe water
or safe water supply Definition of terms: supply
(Level I,II, III) Level I (Point Source) – refers to a protected well (shallow ● Level I
and deep well), improved dug well, developed spring, or ● Level II
rainwater cistern with an outlet but without a distribution ● Level III
system, generally adaptable for rural areas where the
houses are thinly scattered. A level I facility normally Denominator : Total Number
serves around 15 households. of Households

Level II (Communal Faucet System or Standposts) – refers x 100
to a system composed of a source, a reservoir, a piped
distribution network, and a communal faucet located not
more than 25 meters from the farthest house. It is
generally suitable for rural and urban areas where houses
are clustered densely enough to justify a simple piped
water system. Usually, one faucet serves 4‐6 households.
Note: For reporting purposes Level II system may also
include a communal faucet connected to Level III where
group of households get their water supply.

Level III (Waterworks System) – a system with a source,
transmission pipes, a reservoir, and a piped distribution
network for household taps. It is generally suited for
densely ‐ populated areas. Examples of these are MWSS
and water districts with individual household connections.
Note: For reporting purposes Level III system may also
include a Level I system with piped distribution for
household tap serving group of housing dwellings such as
141
Data Reporting
apartments or condominiums

2. Proportion of Refers to households with flush toilets connected to septic Numerator: Total no. of 91% Annual
Households with tanks and/or sewerage system or any other approved Households with Sanitary (National)
Sanitary Toilet treatment system, sanitary pit or ventilated improved pit toilet 96%
Facilities latrine (Urban)
Denominator: Total Number 86%
of Households (rural)
3. Households with Refers to households with garbage disposal through Numerator: Total No. of 41%Metro
satisfactory disposal composting, burying, city / municipal system. Households with satisfactory Manila
of solid waste disposal of solid waste 20% other Annual
Refers on the information collected on the sanitary status highly
of two aspects of solid waste management (storage and Denominator: Total Number urbanized
collection or disposal) of Households areas
4. Proportion of Refers to households which satisfy the presence of the Numerator: Total no. of Annual
Households with following basic sanitation elements, namely: Households with Complete
Complete Basic (1) access to safe water Basic Sanitation Facilities
Sanitation Facilities (2) availability of a sanitary toilet
(3) satisfactory system of garbage disposal Denominator: Total Number
of Households

5. Proportion of Refers to the ratio of the number of food establishments Numerator: Total no. of Food 100 % Annual
Food Establishment with sanitary permit. Establishments with
with Sanitary Sanitary Permit
Permits Definition of terms:
Denominator: Total no. of
Food Establishment – Establishment where food or drinks Food Establishments
are manufactured, processed, stored, sold or served,
including those that are located in vessels. It refers to the
total number of food establishments which includes
restaurants, sari‐sari stores, canteens, coffee shops,
carinderia, refreshment parlors, bakeries, water refilling
station, food manufacturing, bottling, dairy and canning
establishments.
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Data Reporting

Sanitary Permit – the certification in writing of the city or
municipal health officer or sanitary engineer that the
establishment complies with the existing minimum
sanitation requirements upon evaluation or inspection
conducted in accordance with Presidential Decrees No. 522
and 856 and local ordinances.

6. Proportion of Refers to the ratio of the number of food handlers issued Numerator: Total no. of Food 100 % Annual
Food Handlers with with health certificates. Handlers issued Health
Health Certificates Certificates
Definition of terms: Denominator: Total No. of
Food Handlers
Food Handlers – Refers to a person who handles, prepares,
serves food, drink or ice who comes in contact with any
cooking utensils and food vending machines

Health Certificates – a certification in writing, using the
prescribed form, and issued by the municipal or city health
officer to a person after passing the required physical and
medical examinations and immunizations

143
3.5 MATERNAL CARE

_____________________________________________________________________________________________________________________________________________________________

Data Reporting
1. Total no. of No. of deliveries Number of Deliveries

deliveries
2. Proportion of The proportion of pregnant women who had 4 or more Numerator: Number of 90% (NOH RHU ● Monthly An indicator of access and
Pregnant prenatal visits. pregnant women with 4 or 2016) (BHS to utilization of health care during
women with 4 more prenatal visits RHU) pregnancy
or more Definition of Terms:
prenatal visits Denominator: ●Quarterly It is strongly encouraged that
Signs of Pregnancy according to three categories: Total Population x 2.7% (RHU to the first prenatal visit is
a. Presumptive – (1) Breast changes, including feeling next higher during the first trimester so
of tenderness, fullness, or tingling and enlargement or levels) that preventive, promotive
darkening of areola; (2) Nausea or vomiting upon health interventions (such as
arising; (3) Amenorrhea; (4) Frequent urination; (5) micronutrient
Fatigue; (6) Uterine enlargement in which the uterus supplementation, screening
can be palpated over the symphysis pubis; (7) for complications) will be given
Quickening (fetal movement felt by the woman); (8) to women in the earliest
Linea nigra (line of dark pigment on the abdomen); (9) possible time.
Melasma (dark pigment on the face); and (10) Striae
gravidarum (red steaks on the abdomen).

b. Probable – (1) Serum laboratory test revealing the
presence of human chorionic gonadotropin (hCG)
hormone; (2) Chadwick’s sign (vagina changes color
from pink to violet); (3) Goodell’s sign (cervix softens);
(4) Hagar’ s sign (lower uterine segment softens); (5)
Sonographic evidence of gestational sac in which
characteristic ring is evident; (6) Ballottement (fetus can
be felt to rise against abdominal wall when lower
uterine segment is tapped during bimanual
examination); (7) Braxton Hicks contractions (periodic
uterine tightening); and (8) Palpation of fetal outline
through abdomen.
144
Data Reporting

c. Positive ‐ (1) Sonographic evidence of fetal outline;
(2) Fetal heart audible by Doppler ultrasound; and (3)
Palpation of fetal movement through abdomen

4 or more prenatal visits means that at least one visit
occurs during the first trimester, one during the second
trimester and at least 2 visits during the third trimester.
If visits occurred outside the catchments RHU, that visit
should be counted as part of the minimum
requirements.
Trimesters of Pregnancy:
The First Trimester = up to 12 weeks or 0‐84 days
The Second Trimester = 13‐27 weeks or 85‐189 days
The Third Trimester = 28 weeks and more or 190 days and more

Prenatal services include (1) complete physical
examination of pregnant women (pregnancy status) (2)
check for pre‐eclampsia (3) check for anemia (4) check
for syphilis (5) check/screen and treatment for STI and
HIV status (6) respond to observed signs or volunteered
problems (7) give preventive measures (8) advice and
counsel on family planning (9) check on birth and
emergency plan (10) check for nutritional status and
(11) advocacy on breastfeeding.

3. Proportion of Proportion of pregnant women immunized against Numerator: No. of pregnant RHU ● Monthly Assess the level of TT
Pregnant women tetanus, having at least two doses of tetanus toxoid women given 2 doses of (BHS to immunization protection
given 2 doses of during pregnancy. Tetanus Toxoid NSO RHU) among pregnant women.
Tetanus Toxoid ●Quarterly
Denominator: (RHU to
Total Population x 2.7% next higher
level)
4. Proportion of Proportion of pregnant women given TT2 plus during Numerator: Number of 80% (NOH ● Monthly Assess the level of TT
Pregnant Women her last pregnancy. pregnant women given TT2 2016) (BHS to immunization protection
given TT2plus plus RHU) among pregnant women.
145
Data Reporting
Definition of Terms: ●Quarterly
TT2 plus includes 2nd, 3rd, 4th and 5th doses of Tetanus Denominator: (RHU to
Toxoid given to pregnant women. Total Population x 2.7% next higher
level)
5. Pregnant women Proportion of pregnant women given complete iron Numerator: Number of 80% RHU ● Monthly There is a high prevalence of
given complete iron tablet with folic acid supplementation. pregnant women given (BHS to anemia in pregnant mothers.
with folic acid complete iron with folic acid NSO RHU) This indicator will tell us if
supplementation Definition of Terms: supplementation ●Quarterly adequate iron supplementation
Complete iron tablet with folic acid supplementation (RHU to is given or taken by the
refers to 60 mg of elemental iron with 400 mcg Folic Denominator: next higher mother.
acid, once a day for 6 months or 180 tablets for the Total Population x 2.7% level)
entire pregnancy period. The iron tablets referred to
are those given for free to the mother by the RHUs and
BHSs and do not include prescribed iron tablets. Iron
tablet should be given as soon as pregnancy was
diagnosed. If the pregnant women did not take full
course of 180 tablets she will not be considered.

6. Proportion of Proportion of post‐partum women given at least 2 post‐ Numerator: Number of post‐ RHU ● Monthly Majority of maternal morbidity
Post partum partum visits. partum women given at (BHS to and mortality occurs at the
women with at least 2 post‐partum visits NSO RHU) post‐ partum period. It is
least 2 post‐partum Definition of Terms: ●Quarterly important that this
visits Post‐partum visits refers to visits seen by the Denominator: (RHU to complication be detected as
midwife/PHN/MHO at home or at the clinic twice or Total number of population next higher soon as possible.
more than twice after delivery such that first visit x 2.7% level)
should be after 24 hours upon delivery and the second
visit within one week after delivery.
Note: Pregnant women who delivered in the hospital is
already considered seen in the first visit which is 24
hours upon delivery.

7. Post partum Proportion of post‐partum women given complete iron Numerator: Number of post‐ RHU ● Monthly There is a high prevalence of
women given supplementation. partum women given (BHS to anemia in postpartum and
complete iron complete iron NSO RHU) lactating women.
146
Data Reporting
supplementation Definition of Terms: supplementation ●Quarterly

Complete Iron Supplementation refers to 60 mg of Fe (RHU to
with 400 mcg Folic acid, once a day for 3 months or a Denominator: next higher
total of 90 tablets. If postpartum mother did not take Total number of population level)
full course of 90 tablets, she will not be considered. x 2.7%
8. Proportion of 10‐ Complete Iron Supplementation refers to 60 mg of Fe Numerator: Women 10‐49 12.3 % FHSIS Proxy indicator for success in
49 years old women with 400 mcg Folic acid, once a day once menarche years old given iron (50% of intervention to decrease Iron
given Iron starts and until one gets pregnant. supplementation age deficiency among age group
supplementation group) of 10‐49 years old
Denominator: TP for Data taken from Iron
Total Population x 24.6% 2013 Deficiency Survey FNRI 2008

9. Proportion of Proportion of post‐partum or lactating women given Numerator: Number of post‐ 80% RHU ● Monthly Numerous studies have shown
Post partum Vitamin A supplementation partum women given (BHS to that pregnant and
women given Vitamin A supplementation NSO RHU) postpartum/lactating women
Vitamin A Definition of Terms: ●Quarterly have an increase risk of Vitamin
supplementation Vitamin A supplementation refers to 200,000 I.U. of Denominator: (RHU to A Deficiency Disorder (VADD).
Vitamin A capsule within 1 month after delivery Total Population x 2.7% next higher An increase in Vitamin A
level) concentration of the mother,
results to an elevated Vitamin
A concentration in her
breastmilk as well as the
Vitamin A status of her breast
fed child.
10. Proportion Proportion of postpartum women who initiated Numerator: No. of RHU ● Monthly Success of breastfeeding
Postpartum breastfeeding within one hour after giving birth. postpartum women initiated (BHS to initiation ensures continuous
women initiated Initiation of breastfeeding is putting the newly delivered breastfeeding within 1 hour NSO RHU) breastfeeding. This is one way
breastfeeding baby to the mother’s abdomen or chest in prone after giving birth ●Quarterly of evaluating whether birth
within 1 hour position and allowing the newborn to find the mother’s (RHU to attendants advocate
after giving birth breast (skin to skin contact) Denominator: next higher breastfeeding and implement
Total number of total level) “Milk Code” in all facility‐based
population x 2.7% deliveries.

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Data Reporting

11.Percentage of Proportion of pregnant females who are tested for Numerator: Number of SSESS Bi‐annual
pregnant syphilis using Rapid Plasma Reagin (RPR) or Rapid pregnant females who are Manual of
women tested Diagnostic Test (RDT) tested for syphilis using RPR Operations
for syphilis or RDT (Appendix
Disaggregate by age‐group (<15yo, 15 to 17yo, 18 to A.1 ICR);
24yo, >24yo) Denominator: Total number FHSIS TCL
of pregnant females who
consult the health facility for
the first time during that
reporting period

12. Percentage of Proportion of pregnant females diagnosed with syphilis Numerator: Number of SSESS Bi‐annual
pregnant women who are given Penicillin pregnant females who are Manual of
given Penicillin given one dose of Penicillin Operations
Disaggregate by age‐group (<15yo, 15 to 17yo, 18 to for syphilis
24yo, >24yo)

Denominator: Total number (Appendix
of pregnant females are A.1 ICR);
positive for TPHA/TPPA ; OR FHSIS TCL
RDT; OR RPR titer of > 1:8
dilution

148
3.6 FAMILY PLANNING

_____________________________________________________________________________________________________________________________________________________________

Data Reporting

1. Contraceptive The proportion women of reproductive age (15‐49 years of Numerator: 65% (NOH ●Family ● Monthly This indicator is useful for
Prevalence age) who are using (or whose partner is using) any modern Number of women of 2016) Planning (BHS to measuring utilization of FP
Rate for FP method at a given point in time. reproductive age who are TCL RHU) methods. It is a complementary
Modern Family using (or whose partner is ●Quarterly output indicator to total
Planning Definition of Terms: using) a modern FP method ●NSO (RHU to fertility rate.
Method use of at a given point in time next higher
women in Modern Family Planning Method – include Female level Population ‐ based sample
reproductive Sterilization/BTL and Male Sterilization/Vasectomy, Denominator: surveys provide the most
age. intrauterine devices IUD, oral pills, injectables and Number of women of comprehensive data on
implants. NFP Methods include Cervical Mucus Method reproductive age who are contraceptive practice since
(CCM), Basal Body Temperature (BBT), Symptothermal eligible to practice they show the prevalence of all
Method (STM), Standard Days Method (SDM) and contraception (Total methods, including those that
Lactational Amenorrhea Method (LAM). Surgical Population x 12.325% ) required no supplies or medical
sterilization (Female and Male Sterilization) is done those 14.5% x 85% = 12.325% services. Estimates may also
couples who reached their desired number of children. be obtained by smaller‐scale or
more focused surveys and by
Women of reproductive age refer to all women aged 15‐ adding relevant questions to
49 years old. surveys on other topics (e.g.
health program prevalence or
Eligible population or women of reproductive age who are coverage surveys).
at risk of getting pregnant are:
 sexually active, Records kept by organized
 fecund family planning program are
 not pregnant and menstruating another main source of
information about
Excluding are the women who have underwent: contraceptive practice. Such
 hysterectomy records are crucial to effective
 bilateral salpingo oophorectomy, monitoring and management
 bilateral tubal ligation, and of program, and they have the
 husbands or partners who underwent Vasectomy potential to provide timely
149
Data Reporting
updates and detailed trend
information about numbers
and characteristics of program
clients. Program statistics have
the serious drawback,
however, of excluding the use
of contraception obtained
outside the program, including
modern methods supplies

2. No. of Current Current Users (CU) ‐ are FP clients who have been carried Formula for CU at End of
Users over from the previous months after deducting the drop‐ Month/Quarter
outs of current month and adding the new acceptors of
the previous month and adding the Other Acceptors of the = CU of previous month
current month
 Re‐starter (RS) + New Acceptor of previous
 Changing Method (CM) month
 Changing Clinic (CC) + Other acceptors of present
month

‐ Drop‐out of present
month
3. No. of New New Acceptor (NA) – a client using a contraceptive
Acceptors method for the first time or has never accepted any
Modern Family Method who is new to the program

4. No. of Drop‐outs Drop‐outs – If a client fails to return for the next service
date or other conditions (e.g. BSO, Hysterectomy), she is
considered a dropout. The service provider should have
done validation prior to dropping out of the client.

150
3.7 CHILD CARE

__________________________________________________________________________________________________________________________________________________________

Data Reporting
1. Proportion of An infant who has received BCG vaccine anytime after birth Numerator: Number of 90% ●Children ● Monthly Basis for computation of FIC,
Infants given BCG before reaching one year of age. infants given BCG < 1 (BHS to number of unimmunized
Vaccine TCL RHU) children, tracking defaulters,
Denominator: ●Quarterly access to immunization.
Total Population x 2.7% ● NSO (RHU to
next higher
level)

2. Proportion of An infant who received 1st dose of Hepatitis B vaccine Numerator: Number of infant 90% ●Children ● Monthly Basis for the number of
Infants given within 24 hours after birth given HepaB1 within 24 < 1 (BHS to unimmunized children, tracking
Hepatitis B1 within hours after birth TCL RHU) defaulters, access to
24 hours after birth ●Quarterly immunization.
Denominator: ● NSO (RHU to
level)

3. Proportion of An infant who received 1st dose of Hepatitis B vaccine more Numerator: Number of infant 90% ●Children ● Monthly Basis for the number of
Infants given than 24 hours after birth given HepaB1 more than 24 < 1 (BHS to unimmunized children, tracking
Hepatitis B1 more hours after birth TCL RHU) defaulters, access to
than 24 hours after ●Quarterly immunization.
birth Denominator: ● NSO (RHU to
level)

151
Data Reporting
4. Proportion of An infant who received (Pentavalent 1, Pentavalent 2 or Numerator: Number of infant 90% ●Children ● Monthly Basis for computation of FIC,
Infants given Pentavalent 3) before reaching one year old. given Pentavalent 1 / < 1 (BHS to number of unimmunized
Pentavalent 1, Pentavalent 2 / Pentavalent 3 TCL RHU) children, tracking defaulters,
Pentavalent 2, Pentavalent vaccine refers to the combination vaccine of ●Quarterly access to immunization. Assess
Pentavalent 3 DPT‐HepB‐H influenza type B (Hib) Denominator: ● NSO (RHU to population immunity in each
vaccines Total Population x 2.7% next higher cohort of children born.
level)

5. Proportion of An infant who received specific OPV antigens (either OPV1, Numerator: Number of infant 90% ●Children ● Monthly Basis for computation of FIC,
Infants given OPV1, OPV2, or OPV3) before reaching one year old given OPV1/OPV2/ OPV3 < 1 (BHS to number of unimmunized
OPV2, OPV3 TCL RHU) children, tracking defaulters,
Denominator: ●Quarterly access to immunization.
next higher Main indicator for the
level) eradication of Polio
6. Proportion of An infant who received Pneumococcal Conjugate Vaccines Numerator: Number of infant 90% ●Children ● Monthly Basis for computation for the
infants given (PCV 1, PCV 2,PCV 3) before reaching 1 year old given PCV1/PCV2/ PCV3 < 1 (BHS to total population immunity for a
Pneumococcal TCL RHU) certain birth cohort
Conjugate Vaccines Denominator: ●Quarterly
(PCV 1, PCV 2,PCV Total Population x 2.7% (RHU to
3) next higher
level)
7. Proportion of An infant who received one dose of Measles‐containing Numerator: Number of 9‐11 90% ●Children ● Monthly Basis for computation of FIC,
Infants given vaccine at 9‐11 months old. This shall be referred to as the mos. old infant given < 1 (BHS to number of unimmunized
Measles‐containing 1st Measles‐Containing Vaccine (MCV1) Measles‐containing TCL RHU) children, tracking defaulters,
vaccine (MCV1) vaccine (MCV1) ●Quarterly access to immunization. Assess
● NSO (RHU to population immunity in each
Denominator: next higher cohort of children born.
Total Population x 2.7% level)
8. Proportion of A child 12‐15 months of age who received one dose of Numerator: Number of 90% ●Children ● Monthly Basis for computation of FIC,
Children given a MMR. This shall be referred to as the 2nd dose of the children given MMR < 1 (BHS to number of unimmunized
dose of Measles‐ Measles‐containing vaccine (MCV2) TCL RHU) children, tracking defaulters,

152
Data Reporting
Mumps‐Rubella Denominator: ● NSO ●Quarterly access to immunization. Assess
Vaccine Total Population x 2.7% (RHU to population immunity in each
(MMR)(MCV2) next higher cohort of children born.
level)
9. Proportion of An infant who received 2 dose regimen of rotavirus Numerator: Number of infant 90% ●Children ● Monthly Basis for computation for the
infants given vaccine at 6 weeks – 32 weeks of age given Rotavirus Vaccine < 1 (BHS to total population immunity for a
Rotavirus vaccines TCL RHU) certain birth cohort
Denominator: ●Quarterly
Total Population x 2.7% (RHU to (Rota1, Rota 2)
next higher
level)
10. Proportion of An infant who received 1 dose of BCG, 3 doses each of Numerator: No. of Fully 90% ●Children ● Monthly An overall program indicator to
Fully Immunized OPV, 3 doses each of Pentavalent vaccines and 1 dose of Immunized Child (Program < 1 (BHS to assess the proportion of full
Child Measles‐containing vaccine before reaching one year old. yearly TCL RHU) complement of immunization
Denominator: target) ●Quarterly during the first year of life.
X 100 next higher
level)
11. Proportion of A child 12 to 23 months of age who received 1 dose of BCG, Numerator: No. of ●Children ● Monthly Basis for computation for the
Completely 3 doses each of OPV, 3 doses each of Pentavalent vaccines Completely Immunized Child < 1 (BHS to total population immunity for a
Immunized Child and 1 dose of Measles‐containing vaccines TCL RHU) certain birth cohort.
Denominator: ●Quarterly
next higher
level)
12. Proportion of Refers to a child whose: Numerator: ●Children ● Monthly Tetanus Toxoid Immunization is
Child Protected at (1) Mother has received 2 doses of TT during this Total No. of Children whose < 1 (BHS to given to pregnant women in
Birth (CPAB) pregnancy, provided TT2 was given at least a month mothers were given at least TCL RHU) order to protect the newborn
prior to delivery, or TT2 or more ●Quarterly and herself from tetanus.
(2) Mother has received at least 3 doses of TT anytime (RHU to
prior to pregnancy with this child Denominator: next higher Percent of protected at birth
Total No. of live births level) (PAB) is a supplemental
method of determining
coverage protection
153
Data Reporting
(particularly where TT2+ is
unreliable and where DTP1
coverage is high). To monitor
PAB during DTP1 visits, health
workers record whether infants
were protected at birth by the
mother’s TT status. % PAB is
then estimated as: number of
infants protected divide by the
total number of births
13. Proportion of A Child who was exclusively breastfed from birth to 6 Numerator: 70% by Exclusive BF provides optimum
Infants exclusively months of age. Exclusive breastfeeding means no other Total No. of Infants 2016 ●Children ● Monthly nutrition for the first 6 months
breastfed until 6th food (including water) other than breast milk. Drops of th
exclusively Breastfed until 6 < 1 (BHS to of life and the number one
month prescribed vitamins and medication with indication given month TCL RHU) preventive strategy to save
while breastfeeding is still “exclusively breastfed.” during ●Quarterly lives of below five children.
sickness, low birthweight or anemia Denominator: (RHU to This indicator also determines
Total Population x 2.7% next higher the progress of BF practice for
level) program planning and policy
direction and basis for research
agenda to improve BF practice
in the country to assess the
implementation of EO51
14. Proportion of Complementary foods and foods given at 6 months to Numerator: Infants 6‐8 90% by ●Children ● Monthly This will determine continued

infants 6‐8 months compliment breastfeeding months who received 2010 < 1 (BHS to breast feeding and timely,
of age who received solid, semi‐solid or soft TCL RHU) appropriate complimentary
solid, semi‐solid or foods during the previous 95% by ●Quarterly feeding to prevent under
soft food day 2016 (RHU to nutrition
next higher
Denominator: No. of Live level)
births
15. Proportion of This refers to infants referred for newborn screening. No. of Infants referred for 100% ●Children ● Monthly
Infant referred for Referral slips may be used. newborn screening < 1 (BHS to
newborn screening TCL RHU)
Note: NBS Referral is 48 hours of birth to 72 hours ●Quarterly
154
Data Reporting
(RHU to
next higher
level)
16. Infant/Children Refers to Infant/Children given Vitamin A supplementation. Numerator: No. of ●Children ● Monthly
given Vitamin A Infant/Children < 1 (BHS to
supplementation by Recommended Dosage: given Vitamin A 90% (NOH TCL RHU)
Age group 6‐11 months old ‐ 1 dose of 100,000 I.U. One capsule is supplementation 2016) – ●Quarterly
given anytime during the 6‐11 months. for age ● NSO (RHU to
 6‐11 Denominator for 6‐11 mos: group next higher
 12‐59 months old 12‐59 months old ‐ 200,000 I.U. Dosage and duration is 1 Total Population x 1.35% under 6 level)
capsule every six months. years of
Denominator for 12‐59 mos: age
Total Population x 10.8%
17. Infants given Refers to infants 6‐11 months old given Iron drops. Numerator: No. of infants ● Monthly
Iron months old given Iron (BHS to
supplementation RHU)
Denominator for 6‐11 mos: ●Quarterly
Total Population x 1.35% (RHU to
next higher
level)

18. Children 12‐59 Refers to children 12‐59 months old given de‐worming No. of children 12‐59 months ●Children ● Monthly
mos. old given de‐ tablet/syrup twice a year old given de‐worming < 1 (BHS to
worming tablet/syrup TCL RHU)
tablet/syrup ●Quarterly
(RHU to
next higher
level)

19. Infant 6‐11 Refers to infants 6‐11 months old consumed micronutrient Numerator: No. of infant 6‐ ●Children ● Monthly
months consumed powders 11 months old given MNP < 1 (BHS to
60 sachets of TCL RHU)
micronutrient Definition of Terms: Denominator: Total ●Quarterly
powders (MNP) Micronutrient Powder refers to premix vitamins and Population x 1.35% (RHU to
155
Data Reporting
minerals in powder form. next higher
Every child will receive a total of 60 sachets over a period level)
of 6 months
20. Children 12‐23 Refers to children 12‐23 months old consumed Numerator: No. of children ● TCL
months micronutrient powder. 12‐23 months old given
consumed120 MNP
sachets of Definition of Terms:
Micronutrients Micronutrient Powder refers to premix vitamins and Denominator: Total
powder (MNP) minerals in powder form. Population x 2.7%
Every child will receive 60 sachets every 6 months for a
total of 120 sachets in a year.
21. Sick Child / Refers to a child / children 6‐11 and 12‐59 months old seen Number of sick children 6‐ ● Sick ● Monthly
Children 6‐11 mos. and identified as “sick child”. 11, 12‐59 old seen Child (BHS to
and 12‐59 mos. Care RHU)
(disaggregated by Definition of terms: TCL ●Quarterly
sex) “Sick Children” are those children with at least one the (RHU to
following categories: next higher
● Severe pneumonia (refers to presence of any general level)
danger sign or chest indrawing or stridor in calm child)
● Severe persistent diarrhea (refers to an episode of soft to
watery stools lasting more than 14 days)
● Measles (History of fever or hot to touch; generalized
non‐vesicular rash of 3 or more days duration and at
least one of the following: cough, coryza or conjunctivitis
● Severely under weight (refers to children whose weight
are classified as very low below normal)

22. No. of Sick Any sick child / children given Vitamin A capsule. Dosage of Numerator: Number of sick 100% ● Sick ● Monthly Vit.A is given to high risk
Children by age Vitamin A for 6‐11 month‐old infant is 100,000 IU, while 12 children 6‐11/12‐59 Child (BHS to children because it helps re‐
given Vitamin A to 59 month‐old infants are given 200,000 IU (1 capsule months given Vitamin A Care RHU) establish body reserves drained
capsule every 6 months). capsule TCL ●Quarterly by chronic or repeated
(RHU to infections & protects the
 6‐11 mos. Denominator: Number of sick next higher children against severity or
children 6‐11, 12‐59 level) subsequent infections. It also
156
Data Reporting
and months old seen reduces the complications of an
 12‐59 mos. existing measles infection &
lowers measles morbidity &
(disaggregated by mortality.
sex)
23. Infants This refers to infants 2‐5 months old seen with low birth No. of infants 2‐5 months old ●Children ● Monthly
with low birth weight (weight at birth is less than 2.5 kilograms) seen with low birth < 1 (BHS to
weight seen weight TCL RHU)
(disaggregated ●Quarterly
by sex) (RHU to
next higher
level)
24. Infants with This refers to low birth weight (LBW) infants 2‐5 months Numerator: No. of infants 2‐ 100% ●Children ● Monthly Give iron supplements to low
low birth weight old whose weight at birth is less than 2.5 kilograms and 5 mos. old with low birth < 1 (BHS to birth weight infants at 2
given iron was given iron supplementation. Dosage is 0.3 ml once a weight given iron TCL RHU) months, as they are born with a
day to start at two months of age until 5 months when supplementation ●Quarterly lower iron supply and are at
supplementation complementary foods are given. (Preparation is 15 mg. (RHU to high risk for iron deficiency
(disaggregated elemental iron/0.6 ml). Need to assess for further Denominator: No. of infants next higher even if exclusively breastfed.
by sex) management 2‐5 mos. old seen with low level)
birth weight

prevalence of LBW = 19.6 %
25. Anemic Children This refers to anemic children 6 to 59 months old seen. No. of anemic children 6‐11 ● Sick ● Monthly
6‐11 months and months and 2‐59 months old Child (BHS to
12‐59 months Iron–deficiency Anemia – can be diagnosed through clinical seen Care RHU)
old signs and symptoms: TCL ●Quarterly
seen (+) palmar pallor (RHU to
(disaggregated (+) pale conjunctiva next higher
by sex) (+) pale nailbeds level)
(+) pale bucal mucosa
26. Anemic Children This refers to anemic children 6 to 59 months old given Numerator: No. of anemic ● Sick ● Monthly
6‐11months and iron supplementation (syrup). Dosage is 1 tsp. once a day children 6‐11months and Child (BHS to
12‐59 months for 3 months or 30 mg. once a week for 6 months with 12‐59 months old given Care RHU)
old supervised administration. iron supplementation TCL ●Quarterly
157
Data Reporting
given iron (RHU to
Give approximately 0.6 ml, 2‐3 times a day for 3 months Denominator: Number of ● NSO next higher
supplementation anemic children 6‐ level)
(disaggregated 11months and 12‐59 ● ITR
by sex) months old seen
27. Diarrhea cases Refers to children 0‐59 months old seen with diarrhea. No. of diarrhea cases 0‐59 ● Sick ● Monthly
0‐59 months months old seen Child (BHS to
old seen Care RHU)
(disaggregated TCL ●Quarterly
by sex) (RHU to
● ITR next higher
level)
● IMCI
form
28 Diarrhea cases Refers to children 0‐59 months old with diarrhea given Oral Numerator: No. of diarrhea ● Sick ● Monthly Identification of commonly
0‐59 months old Rehydration Salt only. cases 0‐59 months old Child (BHS to used rehydration solution in
given ORS only given ORS Care RHU) diarrhea management for
(disaggregated Definition of terms: TCL ●Quarterly planning/ budgeting purposes
by sex) Oral Rehydration Salt is the non‐proprietary name for Denominator: No. of diarrhea (RHU to
balanced glucose‐electrolyte mixture use for treatment of cases 0‐59 months old ● ITR next higher
clinical dehydration. seen level)
● IMCI
form
29. Diarrhea cases Refers to children 0‐59 months old with diarrhea given Numerator: No. of diarrhea ● Sick ● Monthly Identification of commonly
0‐59 months old ORS/ORT with zinc. Dosage for children less than 6 months cases 0‐59 months old Child (BHS to used rehydration solution in
given ORS/ORT is 10 mg elemental Zn/day and for children more than 6 given ORS/ORT with zinc Care RHU) diarrhea management for
and zinc months is 20 mg elemental Zinc/day x 10‐14 days. TCL ●Quarterly planning/ budgeting purposes
(disaggregated Denominator: No. of diarrhea (RHU to
by sex) Definition of terms: cases 0‐59 months old ● ITR next higher
Oral Rehydration Therapy refers to increase in fluid intake seen level)
and continuous feeding. (advice) ● IMCI
form
30. Pneumonia Refers to children 0‐59 months old seen with pneumonia No. of pneumonia cases 0‐59 ● Sick ● Monthly
cases 0‐59 mos. months old seen Child (BHS to
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Data Reporting
old seen Care RHU)
(disaggregated TCL ●Quarterly
by sex) (RHU to
● ITR next higher
level)
● IMCI
form
31. Pneumonia Refers to children 0‐59 months old seen with pneumonia Numerator: No. of ● Sick ● Monthly
cases 0‐59 mos. and given antibiotic treatment pneumonia cases 0‐59 Child (BHS to
old given months old given Care RHU)
treatment treatment TCL ●Quarterly
(disaggregated (RHU to
by sex) Denominator: No. of ● ITR next higher
pneumonia cases 0‐59 level)
months old seen ● IMCI
form
32. Weight, Weight – reflects attained growth in a physical body weight ● TCL ● Monthly
Length/Height relative to the child’s age on a given day or visit. This (BHS to
indicator also gives a rough overview of a child’s present RHU)
nutritional status ●Quarterly
Length – refers to the measurement in a recumbent (RHU to
position, and is measured for children under 2 years next higher
Standing height – refers to as ‘stature’ and is measured in level)
standing position for children 2 years and over
*Based from the Guidelines on Growth Monitoring and
Promotion, FHO, NCDPC, DOH

159

3.8 DENTAL HEALTH
_____________________________________________________________________________________________________________________________________________________________

Source of Frequency
Data of Reporting
1. Orally Fit Proportion of children 12 to 71 months old and are Numerator: No. of orally fit ● ITR ●Quarterly To measure the outcome of
Children (12‐71 orally fit during a given point in time children 12‐71 months old (RHU to total health care of children less
months old) ● Oral next higher than 6 years old for planning
(disaggregated Definition of Terms: Denominator: Health level) and evaluation.
by sex) Orally Fit Children ‐ refers to children who meet all of TP x 13.5% Form 2
the following upon oral examination and/or completion (Consolidated
of treatment: Oral Health
(1) carries‐free or decayed teeth filled (permanent Status and
fillings) Services
(2) has healthy gums Report)
(3) no oral debris, and
(4) no dento‐facial anomaly that limits normal function ● NSO

2. Children 12‐71 Proportion of children whose ages ranges from 12 to 71 Numerator: Number of ● ITR ●Quarterly To measure the outcome of
months old months old and were provided with Basic Oral Health children (RHU to total health care of children less
provided with Care (BOHC) 12‐71 months old provided ● Oral next higher than 6 years old for planning
Basic Oral with BOHC Health level) and evaluation.
Health Care Definition of terms Form 2
(BOHC) Basic Oral Health Care (BOHC) provided to children 12‐ Denominator:
(disaggregated 71 months old – refers to one or more of the following TP x 13.5% ● NSO

by sex) services:
(1) Oral Examination
(2) 80% Attendance to Supervised Tooth Brushing
(3) Altraumatic Restorative Treatment (ART)
(4) Oral Urgent Treatment (OUT)
‐ removal of unsavable teeth, or
‐ referral of complicates cases, or
‐ treatment of post‐extraction complications, or
‐ drainage of localized oral abscess
160
Source of Frequency
Data of Reporting

3. Adolescent and Proportion of adolescents and youth whose ages Numerator: Number of ● ITR ●Quarterly To measure the outcome of
Youth (10‐24 ranges from 10 to 24 years old and were provided with Adolescent and Youth (RHU to total health care of adolescent
years old Basic Oral Health Care (BOHC) (10‐24 years old) provided ● Oral next higher and youth for planning and
provided with with BOHC Health level) evaluation.
Basic Oral Definition of terms Form 2
Health Care Basic Oral Health Care (BOHC) provided to Adolescents Denominator:
(BOHC) and Youth (10‐24 years old) – refers to one or more of TP x 30% ● NSO
(disaggregated the following services:
by sex) (1) Oral Examination
(2) Education and counseling on health effects of
tobacco/smoking, diet, and oral hygiene
4. Pregnant Proportion of pregnant women who were provided Numerator: Number of ● ITR ●Quarterly To measure the outcome of
women with Basic Oral Health Care (BOHC) Pregnant Women provided (RHU to total health care of pregnant
provided with with BOHC ● Oral next higher women for planning and
Basic Oral Definition of terms Health level) evaluation.
Health Care Basic Oral Health Care (BOHC) provided to Pregnant Denominator: Form 2
(BOHC) Women – refers to one or more of the following TP x 2.7%
services: ● NSO
(1) Oral Examination
(2) Scaling
(3) Permanent Filling
(4) Gum Treatment

5. Older Persons Proportion of older person ages 60 years old and above Numerator: Number of ● ITR ●Quarterly To measure the outcome of
60 years old and who were provided with Basic Oral Health Care (BOHC) Older Persons provided (RHU to total health care of older person
above provided with BOHC ● Oral next higher for planning and evaluation.
with Basic Oral Definition of terms Health level)
Health Care Basic Oral Health Care (BOHC) provided to Older Person Denominator: Form 2
(BOHC) – refers to one or more of the following services: TP x 6.9%
(disaggregated (1) Oral Examination ● NSO
by sex (2) Extraction
(3) Gum Treatment

161

3.9 F I L A R I A S I S

____________________________________________________________________________________________________________________________________________________________

Source of Frequency
Data of Reporting
1. Prevalence rate Microfilaria prevalence (mf%): Proportion of blood Numerator: No. of Prevalence of Filariasis Annual Baseline is 9.7 cases per 1,000
of microfilaria in slides (20microL) found positive for microfilaria. individuals whose slides are microfilaria of <1% Registry population (DOH‐NCDPC 1998)
endemic positive for mf
provinces (Global and (44
Denominator: Total No. of National Standard) provinces)
Baseline shows 0 province has
individuals examined for
<1%
mf

N/D x 100 = MFR
2. Microfilaria MFD: average number of microfilaria in slides Numerator: Total count of Reduce Filariasis Annual
density (MFD) in positive for microfilaria expressed as per mL of microfilaria in the slides microfilaria Registry
endemic capillary blood found positive x 50 density in endemic
municipalities (presuming 20 micro liter municipalities to 0
100 X 50/ 10 = 50 per slide)

Denominator: Number of
slides found positive

3. Mass Drug MDA coverage using eligible population / target Numerator: No. of persons 85% coverage for Filariasis Annual Baseline of 82% mass target
Administration population in endemic provinces Proportion of given MDA eligible population Registry coverage in 30 endemic areas
Coverage among target population covered by MDA during the (DOH‐NCDPC)
eligible population reporting year Denominator: Total
Population aged 2 yrs and
above in implementing units
for MDA x 100
(eligible population)

4. Mass Drug MDA coverage among total population. Numerator: No. of persons 65% coverage for Filariasis Annual
Administration given MDA total population Registry
Coverage among
162
Source of Frequency
Data of Reporting
total population Denominator: Total
Population
5. Clinical Rate of Proportion of people examined showing the Numerator: No. of patients Reduce Filariasis Annual
Filariasis chronic manifestation of LF ex. (Hydrocele, with Lymphedema or adenolymphangitis Registry
Lymphedema, Elephantiasis (lower and upper Hydrocele or Elephantiasis or attacks to one per
extremities, breast, penis and scrotum) and Chyluria year
Chyluria
Denominator: Total
Number of people examined

163
3.10 L E P R O S Y

_____________________________________________________________________________________________________________________________________________________________

Source of Frequency
Data of Reporting
1. Leprosy Prevalence is the number of leprosy cases Numerator: No. of Leprosy Less than one Leprosy ● Monthly Prevalence rate. If the
Prevalence Rate registered at a given point in time and the Cases case per 10,000 Registry (BHS to prevalence rate is high
prevalence rate is per 10,000 total population. Population RHU) (prevalence rate >1 per 10 000
●Quarterly population), this can indicate
A case of leprosy is a person presenting clinical Denominator: Total (RHU to several possibilities: (1) high
signs of leprosy (with or without bacteriological Population x 10,000 next higher transmission in the district (2)
examination) who has yet to complete a full course level) result of leprosy elimination
of treatment. A patient who has completed a full campaigns (3) result of over
course of fixed duration MDT (6 doses for PB and 12 diagnosis (4) result of recycling
doses for MB) is cured. of old patients, or (5) standard
MDT regimen is not followed or
An MB patient who has not collected treatment for low cure rate (accumulation of
6 consecutive months and a PB patient who has not patients) (6) should increase
collected treatment for 3 consecutive months are because of the population
considered defaulter and should start retreatment factor.
but not removed from the prevalence. It also signifies magnitude of
the case loads particularly
Includes: hidden cases in the community
1) still needing treatment (including return after
default)
2) trans in
3) New cases
4) defaulted

Excludes:
1) Treatment completed
2) Cases cured
3) Trans out
4) Died

164
Source of Frequency
Data of Reporting
2. Case detection Detection and detection rate. Number of cases Numerator: No. of Newly Bench mark: Leprosy ● Monthly Detection rate. If the detection
rate newly detected during the reporting period and Detected cases during Less than 5% from Registry (BHS to rate is high, the possibilities are
never treated before. The detection rate is per reporting period previous year RHU) the same as the first four above
100,000 total population. ●Quarterly plus community awareness
Denominator: Total (RHU to may be increasing. If the trend
Population x 100, 000 next higher is decreasing, the following
level) possibilities should be
considered: 1) transmission is
decreasing, 2) MDT services are
becoming less active, or 3)
image of leprosy has been
damaged.

Regarding (2) MDT services are
becoming less active, it is
natural to some extent that the
detection decreases after
intensified case finding
activities like leprosy
elimination campaigns. Review
if the rest of the services are
not deteriorating. Regarding (3)
image of leprosy has been
damaged, IEC activities could
have a negative impact on the
image of leprosy. Review IEC
materials and interview
patients and the community.
The most useful indicators for
estimating the magnitude of
the problem and the level of
on‐going transmission. Case
detection is also essential on
calculating drug needs.
165
Source of Frequency
Data of Reporting
3. Proportion of The number of newly diagnosed patients below the Numerator: No. of Leprosy Bench mark: Leprosy ● Monthly Gives an indication of on‐going
newly detected age of 15 divided by the number of newly detected cases below 15 years of Less than 3% from Registry (BHS to transmission
leprosy cases patients age previous year RHU)
below 15 years ●Quarterly
of age Denominator: No. of newly (RHU to
detected Leprosy cases next higher
level)

4. Proportion of Method of calculation of percentage with Grade 2 Numerator: No. of Leprosy Bench mark: Leprosy ● Monthly Gives an indication of the delay
newly detected disability in leprosy is caused by damage of the cases with Grade 2 Less than 5% from Registry (BHS to between onset of symptoms
cases with peripheral nerves disability previous year RHU) and the start of treatment and
grade two ●Quarterly the severity of the disease in
disability Denominator: No. of newly (RHU to new cases
detected Leprosy cases next higher
level)
Cure rate. Number of patients who have received a Numerator: No. of Leprosy 100% Leprosy 5. Cure rate Cure rate, defaulter rate. Cure
complete treatment (6 blisters for PB patients and cases got cured Registry rate should be as close to 100%
12 blisters for MB patients) in a group of patients (treatment as possible‐‐it should be
detected during a given period 6‐9 months for PB Denominator: Total No. of ensured that all patients
patients and 12‐18 months for the MB patients for Leprosy cases completion) registered for treatment are
the cohort analysis). cured. Low cure rates, high
defaulter rates and high
To facilitate the calculation of the average cure proportion of patients still on
rate, it is recommended to take the same period of treatment after having
one year before the report period, as well as for PB completed the standard
and MB patients, divided by the number of patients regimen can indicate following
detected in the selected period. problems: (1) MDT service not
flexible. Improve service
delivery to be more patient
friendly (2) Patient follow‐up is
not satisfactory. Should
improve follow‐up of irregular
patients wherever possible (3)
patient is not well informed of
importance of continuing MDT.
166
Conduct proper patient
education and counseling (see
Guide for Health Professionals
to Eliminate Leprosy as a Public
Health Problem) and (4) MDT
was not always available. Keep
sufficient MDT stock and
improve stock management.

Important for assessing the
quality of patient management
as well as program
performance

167
3.11 M A L A R I A

____________________________________________________________________________________________________________________________________________________________

Source of Frequency
Data of Reporting
1. Morbidity rate of Number of confirmed malaria cases over total Numerator: No. of ● 15 cases per Malaria ● Annual
Confirmed Malaria (per population x 100,000 disaggregated by sex and confirmed malaria cases 100,000 Registry
100,000 population) age (>5 and <5 years of age) population in
Denominator: stable risk
Types of transmission: Total Population x 100,000 provinces
 Stable Risk – with at least 1 barangay
that has a continuous malaria case in a ● 2.6 cases per
month for 6 months or more at anytime 100,000 in
during the past 3 years unstable and
sporadic risk
 Unstable Risk – with at least 1 barangay provinces
that has a continuous presence of at
least one indigenous malaria case in a
month for less than 6 months at anytime
during the past 3 years

 Sporadic Risk – with at least 1 barangay
that has a presence of at least one
indigenous malaria case at anytime in
the past 5 years
2. Annual Parasite Number of confirmed malaria cases over Numerator: No. of Malaria < 0.1/1,000 Malaria ● Annual To know which provinces are
Incidence population at risk x 1,000 disaggregated by sex cases in the population Registry at pre‐elimination phase
and age
Denominator: At risk
Population at risk – refers to the population of Population x 1,000
endemic areas with a high risk of Malaria cases.
3. Laboratory‐ Laboratory‐confirmed malaria cases denote, for Numerator: Total No. of Malaria ● Quarterly In many countries the only
confirmed areas performing laboratory confirmation of Confirmed Malaria Cases Registry data presently reported
malaria cases malaria diagnosis, all patients with signs and/or routinely
symptoms of malaria and laboratory‐confirmed Denominator: No. of are the number of malaria
diagnosis who received antimalarial treatment. Malaria cases seen cases (severe and
Disaggregated by: Laboratory diagnosis consists of either slide uncomplicated), the majority
168
Source of Frequency
Data of Reporting
 age microscopy or a rapid diagnostic test. of which are based on

 sex Presumptive diagnosis rather
 pregnancy than parasitological
 species confirmation. While these
data are limited and
frequently represent only a
small proportion of malaria
cases. If there are no major
changes in the reporting
system, an understanding of
these limitations will allow for
use of the data to generate
estimates of the overall
burden of disease affecting
communities and for tracking
trends over time.
4. Laboratory‐ Laboratory‐confirmed malaria cases either by Numerator: No. of Malaria ● Quarterly
confirmed slide or RDT confirmed Malaria cases by Registry
malaria cases slide/RDT
by method
Denominator: Total no. of
disaggregated by: Confirmed Malaria cases

● Slide microscopy
● Rapid
Diagnostic
Test (RDT)

5. Proportion of Number of Population at risk (per barangay) given Numerator: Number of 85% protected in Malaria ● Annual To assess the percentage of
Population given LLIN LLIN persons living in at risk area an endemic area Registry LLIN coverage in endemic
given LLIN areas, taking note that 1 LLIN
LLIN – Long Lasting Insecticide Nets 1 LLIN for 2 is for 2 persons.
Denominator: Population at persons
risk
169
Source of Frequency
Data of Reporting
X 100

6. Malaria Mortality Total number of malaria deaths per year among Numerator: No. of Malaria 0.05 deaths or Malaria ● Annual
Rate target group divided by mid‐year population of Deaths less per 100,000 Registry
the same target group disaggregated by sex. population MTDP
Denominator: Total (Medium Term
Population x 100,000 Development
Plan) stable

0.04 death or less
per 100,000 pop
in unstable and
sporadic

7. Malaria Case Number of Malaria deaths over total number of Numerator: No. of Malaria Malaria ● Monthly Determine severity of disease
Fatality Ratio malaria cases disaggregated by sex. Deaths Registry (BHS to
RHU)
Denominator: Total Malaria ●Quarterly
Cases (RHU to
next higher
level)

170

3.12 SCHISTOSOMIASIS
____________________________________________________________________________________________________________________________________________________________

Frequency
Indicator Definition Formula Target Source of Data Use and Limitation
of Reporting
1. Prevalence of Prevalence of infection gives the number of Numerator: No. of 85% reduction in Schistosomiasis Annual ● To determine the
infection infected people in the population per 100,000 individuals positive 28 endemic Registry status/magnitude of
population Schistosomiasis provinces schistosomiasis problem
● To evaluate if the rate of old
Denominator: No. of cases and new infections are
examined X 100,000 decreasing or increasing
2. Proportion of Can be expressed through mean epg. Numerator: No. of Schistosomiasis Annual ● To quantify the individuals
intensity of No. of epg = Number of ova x 24 Low, medium, high Registry suffering of severe
infection infected consequences
The intensity of infection gives information on the ● To decide on appropriate
severity (worm burden) of an infection. Denominator: No. of intervention measures
POSITIVE cases ●To monitor the results and
impact of program (% fall in
arithmetic or geometric mean
egg per gram (epg) counts)
3. Proportion of CRASS gives the information in the number of Numerator: No. of persons Schistosomiasis Annual
Schistosomiasis persons infected based on the clinical signs and with S/S Registry
with clinical symptoms with or without hepatomegaly.
signs and Cross‐reaction Denominator: Total No. of
symptoms SJ (Schistosomiasis Japonicum) case definition = 1 persons in the area/school
major and 2 minor S/S with or without of intervention
hepatomegaly
4. Proportion of Treatment of cases is the administration of Numerator: No. of cases Schistosomiasis Annual ● To determine if all cases
schistosomiasis Praziquantel, 600 mg given just one day in 2‐3 treated Registry found were treated
cases divided doses at 40‐60 mg/kg ●To address ethical issues of
treated Denominator: Total No. of non‐treatment
Positive Cases ● To evaluate drug utilization
and consumption

5. Proportion of Percentage of complicated Schistosomiasis cases Numerator: No. of Schistosomiasis Annual Referred cases to hospitals are
171
Frequency
of Reporting
complicated referred to hospital facility. complicated cases referred Registry complicated cases with high
Schistosomiasis to hospital facility index of suspicion which the
cases referred primary health facilities cannot
to hospital Denominator: Total No. of manage, ex. (1) Neurologic
facility Schistosomiasis cases cases (2) Spinal
detected (3) Cardiovascular (cor
pulmonale) (4) Hepatic or
renal complications (5) Pipe
System fibrosis(6)
Hypertensive

172

3.13 TUBERCULOSIS

_____________________________________________________________________________________________________________________________________________________________

Frequency
of Reporting
1. Number of TB This refers to all TB Symptomatics who underwent Number of TB Symptomatics NTP Laboratory ●Quarterly To assess the case finding
symptomatics DSSM. who underwent DSSM Register (RHU to activities of a DOTS facility.
who underwent next This will also be used to
Direct Sputum Definition of terms: higher level) estimates for the logistics
Smear TB Symptomatics – refer to a patient with cough needed in the laboratory
Microscopy of two weeks or more with or without the activities of the DOTS facility.
(DSSM) following signs and symptoms: fever, chest or
back pains, hemoptysis or blood streaked sputum,
significant weight loss or other symptoms such as
sweating, fatigue, body malaise and shortness of
breath.

2. Number of This refers to TB symptomatics with smear Number of smear positive NTP Laboratory Quarterly To determine the positivity
smear positive positive results in the NTP Laboratory Registry. discovered / identified Register rate which measures the
discovered / quality of screening of TB
identified Smear positive patients are those patients with at Symptomatics and microscopy
least 1 sputum smears positive for AFB. work in a DOTS facility.

3. Number of new This refers to the number of new smear positive Number of new smear TB Case Quarterly To assess the Case Notification
smear positive cases given treatment and registered in a DOTS positive cases initiated Registry Rate and Case Detection Rate
cases initiated facility. treatment of new smear positive cases in
treatment and an area
registered TB patients with positive DSSM result that have
not taken anti‐TB drugs before or if they have
taken anti‐TB drugs it is for less than 1 month.

to compute CDR for new smear positives:

173
Frequency
of Reporting
CDR = new smear positives/{ total population x
0.00131 (Incidence Rate for new smear positive)} x
100
4. TB Case Summation of all forms of TB pertaining to new Numerator: Number of all 85% (NOH 2016) Quarterly
Detection Rate (All smear positive , new smear negative , relapse and forms of TB Cases identified reports (All
forms of TB) extra pulmonary TB forms refer to
Denominator: estimated new smear
To compute for CDR all forms: number of all forms of TB positive, new
cases for the year smear negative,
CDR all forms = total number of all forms of TB/ relapse and
{total population x 0.00275 (estimated TB All Multiplier: X 100 extrapulmonary
Forms)} x 100 TB)

5. Number of all This refers to the number of all forms of TB cases Number of New Smear TB Case ●Quarterly To assess the CNR and CDR of
forms of TB (new smear positive, new smear negative, relapse, positive cases initiated Registry (RHU to all forms of TB in an area
cases initiated extra pulmonary TB) regardless of age given treatment and registered next
treatment and treatment who are registered in TB Case Registry higher
registered of the DOTS facility. + Number of smear Negative level)
Cases initiated treatment
All forms of TB include the ff: and registered
 New smear positive
 New smear negative + Number of relapse cases
 Relapse initiated treatment and
 Extra pulmonary TB registered

+ Number of extra‐
pulmonary cases initiated
treatment and registered
5. Number of new This refers to the number of new smear positive Number of new smear TB Case Quarterly To assess the quality of DOTS
smear‐positive cases who have completed treatment and is positive cases at start of Registry services provided.
cases cured a smear negative in the last month of treatment treatment who have
year ago and on at least one previous occasion in the completed treatment and
continuation phase. smear negative in the last
month of treatment and on
To compute for New Smear Positive Cure Rate: at least 1 previous occasion
174
Frequency
of Reporting
in the continuation phase
New Smear Positive CR = new smear positive cases
who got cured/ new smear positive cases detected
for that quarter

6. Number of This refers to the number of smear positive re‐ Number of smear positive TB Case ●Quarterly To assess the trend of re‐
smear positive treatment cases given treatment and registered in re‐treatment cases initiated Registry treatment cases for they are
re‐treatment a DOTS facility. treatment already suspects for drug
cases initiated resistance.
treatment and Re‐treatment cases refers to:
registered
 Relapse,
 Return after Default,
 Treatment Failure, and
 Other type of TB cases – does not fall in
any of the mentioned above but is
positive.

7. Number of This refers to the number of smear positive re‐ Number of smear positive TB Case ●Quarterly To assess the quality of DOTS
smear positive treatment cases: re‐treatment cases who got Registry services provided and to
re‐treatment cured determine if DOT is being
cases who got a. Relapse cases cured are those who have done.
cured completed treatment and are smear
negative in the last month of treatment
and on at least one previous occasion in
the continuation phase.

b. Return after Default cured are those
who have completed treatment and is
smear negative in the last month of
treatment and on at least one previous
175
Frequency
of Reporting
occasion in the continuation phase.

c. Treatment Failure cured are those who
have completed treatment and is smear
negative in the last month of treatment
and on at least one previous occasion in
the continuation phase.

176

3.14 MORBIDITY RATES
_____________________________________________________________________________________________________________________________________________________________

Source of Frequency
Data of Reporting
1. Top ten leading
cause of morbidity

2. Morbidity rate of NOTE: Numerator: No. of notifiable
Notifiable  Notifiable diseases include: both disease cases among the
diseases among the communicable & non‐communicable elderly
elderly (per 100,000 diseases - 60‐64 yrs old
pop) by gender &  The cut‐off of the age of elderly persons - 65‐69 yrs old
age group (60‐64 will be 60 years old instead of 65 years - 70 yrs & above
yrs; 65‐69 yrs & 70 old to harmonize with the definition in
yrs & above) Republic Act 9994 (Expanded Senior Denominator: Total
Citizens Act of 2010). An elderly or senior population (age group: 60‐64
citizen of the Philippines at least sixty (60) yrs; 65‐69 yrs & 70 yrs &
years old. above)
 For the age groupings among the elderly,
can we follow the disaggregation used in Multiplier: X 100,000
the Phil. Health Statistics:
- 60‐64 years old
- 65‐69 years old
- 70 years old & above
3. Influenza NOTE: Numerator: No. of influenza
Mortality Rate  Cut‐off the elderly & age groupings – deaths among the elderly
among the elderly same as above - 60‐64 yrs old
(per 100,000 pop) - 65‐69 yrs old
by gender & age - 70 yrs & above
group (60‐64 yrs;
65‐69 yrs & 70 yrs & Denominator: Total
above) population (age group: 60‐64
yrs; 65‐69 yrs & 70 yrs &
above)
177
Source of Frequency
Data of Reporting
Multiplier: X 100,000
4. Pneumonia Pneumonia deaths among elderly Numerator: No. of
Mortality Rate pneumonia deaths among
among the elderly NOTE: the elderly
(per 100,000 pop)  Cut‐off the elderly & age groupings – - 60‐64 yrs old
by gender & age same as above - 65‐69 yrs old
group (60‐64 yrs;  Laboratory‐confirmed - 70 yrs & above
65‐69 yrs & 70 yrs &
above) Denominator: Total
population (age group: 60‐64
yrs; 65‐69 yrs & 70 yrs &
above)

Multiplier: X 100,000

5. Prevalence of Proportion of the population >25 y/o at risk for Numerator: >25 y/o at risk Still to be Operations Monthly
>25 y/o at risk for CVD event in 10 yrs for CVD event (by level of identified Manual on
CVD event in 10 risk) in 10 yrs the
years Philippine
Disaggregated by Denominator: total Package of
level of risk population >25 y/o X 100 Essential
Level NCD
 <10% risk interventions
 <20% risk (Phil Pen) on
 <30% risk the
 <40% risk Integrated
 >=40% risk Management
of
Hypertension
and Diabetes
for Primary
Health Care
Facilities
(Annex 4.
178
Source of Frequency
Data of Reporting
Patients
Record)
5. Number of cases All individuals with urethral discharge that are Number of individuals with SSESS Monthly
with urethral diagnosed by inspection urethral discharge that are Manual of
discharge diagnosed by inspection Operations
(Syndrome Disaggregate by sex, and age‐group (<15yo, 15 to (Appendix
Reporting) 17yo, 18 to 24yo, >24yo) A.1 ICR);
FHSIS ITR
6. Number of cases All individuals with genital ulcers that are Number of individuals with SSESS Monthly
with genital diagnosed by inspection genital ulcers that are Manual of
ulcer (Syndrome diagnosed by inspection Operations
Reporting) Disaggregate by sex, and age‐group (<15yo, 15 to (Appendix
17yo, 18 to 24yo, >24yo) A.1 ICR);
FHSIS ITR
7. Percentage of All females who have a cervical smear and are Numerator: Number of SSESS Monthly
gonorrhea cases found to have gram negative intracellular smears that are found to Manual of
among smears diploccoci have gram negative Operations
done (Etiologic intracellular diplococci (Appendix
Reporting) All males who have a urethral or anal smear and A.1 ICR);
are found to have gram negative intracellular Denominator: Total number FHSIS ITR
diplococci of smears done

Disaggregate by sex, and age‐group (<15yo, 15 to
17yo, 18 to 24yo, >24yo)
8. Percentage of All individuals who are positive for syphilis Numerator: Number of tests SSESS Monthly
syphilis cases that are positive for Manual of
among RPR Disaggregate by sex, and age‐group (<15yo, 15 to Treponema Pallidum Operations
screening done 17yo, 18 to 24yo, >24yo) Hemaglutination Assay or (Appendix
(Etiologic TPHA A.1 ICR);
Reporting) FHSIS ITR
Denominator: Total number
of RPR screening tests done

179
___________________
ANNEXES
Republic of the Philippines
Departmentof Health
NATIONAL EPIDEMIOLOGY CENTER
Bldg. # g,SanLazaro Compound,Rizal Avenue,Sta.Cruz, 1003Manila
Telefax:rc32\743-8301loc.1900 Trunkline:743-8301 local1900-1907Directline:743'1937
URL : http:iiwww.doh. gov.ph ; E-mail : nec@doh.gov.ph
FOR : ALL CHD RegionalDirectors
ATTENTION: ALL FHSIS Regional/ProvinciaVCity Coordinators
FROM nNNqtWt*{G, MD,PHSAE, cESovI

FPSMTD,
DirectorIV U
/
SUBJECT FHSIS Family Planning Calculation Correction on Current

Users
DATE September312010
The following is an updateon the Family PlanningCurrentUsersFormula and

Calculation.
GUIDE IN FILLING-UP THE FORMS:
1. FOR MONTHLY FORM for FAMILY PLAI\NING
Current UsersBeg. Month (ex. February)

Formula:Just carry over the CU data of previous month (January)
New Acceptors(ex. February)

Formula: Count Total No. of New Acceptorsfor the month of Februaryin the
TCl/Summary Tables
o Other Acceptors(ex. February)

Formula: Count Total No. of OtherAcceptorsfor the Month of Februaryin
the TCl/Summarv Tables
Cc: NCDPC (Family PlanningProgram)
181
• Current Users End. Month (ex. February)
Calculation:
Current users from the previous month (Jan)
+ New Acceptors (previous month) (Jan)
+ Other Acceptor (current month) (Feb)
- Drop-outs (current month) (Feb)
= Current User of ending month (Feb)
Example: Calculation for the Month of January to March
Given: New Acceptors for the month of December = 8
Month CU New Other Dropouts CU

Beg Mo. Acceptors Acceptors End Mon
January 15 6 7 1 29 = (15 + 8
+ 7 – 1)
February 29 3 4 2 37= (29 + 6
+ 4 – 2)
March 37 8 9 5 44 = (37 + 3
+ 9 – 5)
2. FOR QUARTERLY FORM (ex. for First Quarter)
• Current Users Beg. Quarter (ex. First Quarter)

Formula: Just carry over the CU data at the start of the First Quarter
(January)
• New Acceptors (ex. First Quarter)

Formula: Count Total No. of New Acceptors for the First Quarter (January to
March) from the TCL/Summary Tables
• Other Acceptors (ex. February)

Formula: Count Total No. of Other Acceptors for the First Quarter (January to
March) in the TCL/Summary Tables
• Dropouts (ex. February)

Formula: Count Total No. Of Dropouts for the First Quarter (January to
March) in the TCL/Summary Tables
• Current Users End. Quarter (ex. First Quarter)

Formula: carry over the CU end of the month data from the last month of the
Quarter (March) for First Quarter
Cc: NCDPC (Family Planning Program)
182
January 15 6 7 1 29
February 29 add 3 add 4 add 2 37
March 37 8 9 5 44
First Quarter 15 17 21 8 44

April 44 2 6 5 53
May 53 add 1 add
3 add
4 54
June 54 3 7 9 53
Second Quarter 44 6 16 18 53
Cc: NCDPC (Family Planning Program)
183
Annex 2. Individual Treatment Records
2.1 Management of the Sick Young Infant Age 1 Week up to 2 Months
2.2 Management of the Sick Child Age 2 Months up to 5 Years
2.3 Children Under‐Five Years of Age with Health Problems other than IMCI
Classification / Other Children / Adults
2.4 Maternal Client Record for Prenatal Care
2.5 Maternal Client Record for Post‐partum and Neonatal Care
2.6 Family Planning Service Record
2.7 Dental Health Program – Form 1
2.8 TB Program – Individual Treatment Card
2.9 ITR for Malaria Prevention and Control Program
2.10 ITR for the Leprosy Prevention and Control Program
2.11 ITR for the Schistosomiasis Prevention and Control Program
2.12 ITR for the Filariasis Prevention and Control Program

184
Annex 2.1 Department of Health
Integrated Management of Childhood Illness Strategy
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No. __________

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Date: ____________
Child’s Name: _________________________ Age: ____ Sex: ____ Weight: _____ kg Temperature: ______ºC
Address: ________________________________________ Mother’s Name: _______________________________
ASK: What are the child’s problems? _______________________ Initial visit? __________ Follow-up visit? ________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR POSSIBLE BACTERIAL INFECTION
 Has the infant had convulsions?  Count the breaths in one minute. ____ breaths per minute.
Repeat if elevated _____. Fast breathing?
 Look for severe chest indrawing.
 Look for nasal flaring.
 Look and listen for grunting.
 Look and feel for bulging fontanelle.
 Look for pus draining from the ear.
 Look at the umbilicus. Is it red or draining pus? Does the
redness extend to the skin?
 Fever (temperature 37.5C or above or feels hot) or low body
temperature (below 35.5C or feels cool)
 Look for skin pustules. Are there many or severe pustule?
 See if the young infant is abnormally sleepy or difficult to
awaken.
 Look at young infant’s movements. Less than normal?
DOES THE YOUNG INFANT HAVE DIARRHEA? Yes ___ NO ___
 For how long? ___ Days  Look at the young infant’s general condition. Is the infant:
 Is there blood in the stools? Abnormally sleepy or difficult to awaken
Restless or irritable?
 Look for sunken eyes.
 Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
 Is there any difficulty feeding? Yes __ No__  Determine weight for age. Low ___ Not Low ___
 Is the infant breastfed? Yes __ No __
If Yes, how many times in 24 hours? __ times
 Does the infant usually receive any other foods or
drinks? Yes ___ No ___
If Yes, how often?
 What do you use to feed the child?
If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or
is low weight for age AND has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
Has the infant breastfed in the previous hour? If infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.
 Is the infant able to attach? To check attachment, look for:
- Chin touching breast Yes __ No __
- Mouth wide open Yes __ No __
- Lowe lip turned outward Yes __ No __
- More areola above than below the mouth Yes __ No __
no attachment at all not well attached good attachment
 Is the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?
not suckling at all not suckling effectively suckling effectively
 Look for ulcers or white patches in the mouth (thrush)
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS Circle immunizations needed today. Return for next
immunization on:
____ _____ _____ _____ ____________
BCG DPT1 OPV1 HEP B1 (Date)
ASSESS OTHER PROBLEMS:

185
TREAT
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Return for follow-up in: ___________________________________
Give any immunization needed today: _______________________
Feeding Advice: _________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________ ____________________
Name of Health Worker Signature
186
Annex 2.2 Republic of the Philippines
Department of Health-ARMM
Integrated Management of Childhood Illness Strategy
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No. __________
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Date: ____________
Child’s Name: ____________________________ Age: _____ Sex: ______ Weight: _______ kg Temperature:
_________ºC
Address: ____________________________________________ Mother’s Name: ______________________________________
ASK: What are the child’s problems? ___________________________ Initial visit? ______________ Follow-up visit? _________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN YES ___ NO ___
CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes ___ No ___
 For how long? ___ days  Count the breaths in one minute.
____ breaths per minute. Fast breathing?
 Look for chest indrawing.
 Look and listen for stridor.
DOES THE CHILD HAVE DIARRHEA Yes ___ No ___
 For how long? ___ days  Look at the child’s general condition.
 Is there blood in the stools? Abnormally sleepy or difficult to awaken?
Restless or irritable?
 Look for sunken eyes.
 Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
 Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5ºC or above) Yes ___ No ___
Decide Malaria Risk
 Does the child live in a malaria area?  Look or feel for stiff neck.
 Has the child visited a malaria area in the past 4  Look for runny nose.
weeks?
If malaria risk, obtain a blood smear.
+ Pf Pv - Not done Look for signs of MEASLES.
 For how long has the child had fever? __ days.  Generalized rash and
 If more than 7 days, has fever been present every  One of these: cough, runny nose or red eyes.
day?
 Has the child had measles within the last 3 months?
If the child has measles now or  Look for mouth ulcers.
within the last 3 months If yes, are they deep and extensive?
 Look for pus draining from the eye.
 Look for clouding of the cornea.
Dengue Risk:
Then ask:
 Has the child had any bleeding from the nose or gums  Look for bleeding from nose or gums
or in the vomitus or stools?  Look for skin petechiae.
 Has the child had black vomitus or black stool?  Feel for cold and clammy extremities.
 Has the child had persistent abdominal pain?  Check capillary refill. _____ seconds.
 Has the child been vomiting?  Perform tourniquet test if child is 6 months or older AND
has no other signs AND has fever for more than 3
days. (+) (-) (not done)
DOES THE CHILD HAVE AN EAR PROBLEM? Yes ___ No ___
 Is there ear pain?  Look for pus draining from the ear
 Is there ear discharge?  Feel for tender swelling behind the ear.
If Yes, for how long? ______ days
THEN CHECK FOR MALNUTRITION AND  Look for visible severe wasting.
ANEMIA  Look for edema of both feet.
 Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
 Determine weight for age.
Very low?
CHECK THE CHILD’S IMMUNIZATION STATUS Circle immunizations needed today.
____ ____ _____ ______ Return for next
BCG DPT1 OPV1 HEP B1 immunization on:
____ _____ ______ ______
DPT2 OPV2 HEP B2 AMV 1 ___________
____ _____ ______ _______ (Date)
DPT3 OPV3 HEP B3 AMV 2
CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older Vitamin A needed
Is the child six months of age or older? Yes __ No ___ today
Has the child received Vitamin A in the past six months? Yes __ No ___ Yes ___ No ___
187
ASSESS CHILD’S FEEDING If child has ANEMIA OR VERY LOW WEIGHT or is less than 2 years old. Feeding
 Do you breastfeed your child? Yes ___ No ____ Problems:
If Yes, how many times in 24 hours? __ times. Do you breastfeed during the night? Yes ___ No ___
 Does the child take any other food or fluids? Yes __ No ___
If Yes, what food or fluids? ________________________________________________________________
How many times per day? __ times. What do you use to feed the child? ____________________________
If very low weight for age: how large are servings? _____________________________________________
Does the child receive his/her own serving? ____ Who feeds the child and how? _____________________
 During the illness, has the child’s feeding changed? Yes ___ No ___
If Yes, how?
ASSESS OTHER PROBLEMS:
188
TREAT
Remember to refer any child who has a danger

sign and no other severe classification.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Return for follow-up in: ___________________________________
Advise mother when to return immediately:
Give any immunizations needed today: _______________________
Give vitamin A if needed today: _____________________________
Feeding Advice: _________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________ ____________________
Name of Health Worker Signature
189
Department of Health-ARMM
Annex 2.3
INDIVIDUAL TREATMENT RECORD (ITR)
Children and Other Adults
A. Patient’s Personal Profile Family Serial No. __________________
Patient’s Name: ______________________________________________________ Sex: _______

Family Name First Name Middle Name
Birthdate:______________________________________ Civil Status:___________
Occupation:________________________________ Agency/Company:_______________________
Parent/Guardian/Contact Person:______________________________________________________
Address: __________________________________________________________________________
Contact Number: ____________ Health Insurance Membership: ___________________________
B. Patient’s Case Summary
Date of Visit:____________________ Age (in months if under five years of

age):______
I. Subjective Complaints:
Chief Complaint: ___________________________________________________________
Present Illness: ____________________________________________________________

__________________________________________________________________________
__________________________________________________________________________
Past History:_______________________________________________________________
__________________________________________________________________________
II. Objective findings:
Vital signs: BP if needed:______ Heart Rate: _______ Respiratory Rate:_______

Temperature: _______ Weight:__________ Height:__________
Physical Examination:_______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
III. Assessment/Classification:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
IV. Plan of Management: (Treat, Refer and Health Educate)

__________________________________________________________________________
__________________________________________________________________________
_____________________________________
Name and Signature of Service Provider
190
Annex 2.4
Republic of the Philippines MNC Form I SIDE A
MATERNAL CLIENT RECORD for Prenatal Care Family Serial NO.
MEDICAL HISTORY PHYSICAL EXAMINATION
NO. OF LIVING CHILDREN: _____

AVERAGE MONTHLY Family INCOME ______________
NAME OF SPOUSE: _____________________ __________________ ____
NAME OF CLIENT: _____________________ __________________ ____

REVIEW OF SYSTEMS VITAL SIGNS
HEENT Blood Pressure: ___________ mm Hg
Epilepsy/Convulsion/Seizure Weight: ___________ kg
Severe headache/dizziness Pulse Rate: ____________/ min
Visual disturbance/blurring of vision CONJUNCTIVA
Yellowish conjunctiva Pale Yellowish
Enlarged thyroid NECK
CHEST/HEART Enlarged thyroid Enlarged lymph nodes
Severe chest pain BREAST
Shortness of breath and easy fatigability Mass
Breast/axillary masses Right Left Breast
Nipple discharges (specify if blood or pus)
LAST NAME
Last NAME
Breast
ABDOMEN
Mass in the abdomen
History of gallbladder disease
History of liver disease
BIRTH PLAN: □ Hospital □ RHU □ LIC □ Home IF AT HOME, WHO IS THE Birth Attendant: □ SBA □ Non-SBA
GENITAL
Vaginal discharge Nipple discharge
Intermenstrual bleeding Skin – orange peel or dimpling
Postcoital bleeding Enlarged axillary lymph nodes
Mass in the uterus THORAX
GIVEN NAME
GIVEN NAME
EXTREMITIES Abnormal heart sounds/cardiac rate
Severe varicosities Abnormal breath sounds/respiratory rate
Swelling or severe pain in the legs not related to ABDOMEN
injuries Enlarged liver Tenderness
SKIN Mass Scar
Yellowish skin
FAMILY HISTORY
M.I.
M.I.
CVA (strokes) VAGINAL EXAMINATION:
Hypertension Bleeding Discharges Cyst/mass
____/____/________
DATE OF BIRTH (mo/day/year)
Scars Warts Laceration

Asthma
____/____/________ _______________
Heart disease Others (Specify)________________________
Diabetes
PAST HEALTH HISTORY EXTREMITIES
Allergies Edema
Drug intake (anti-tuberculosis, anti-diabetic, Varicosities
anticonvulsant) Pain on forced dorsiflexion
Bleeding tendencies (nose, gums, etc.)
Anemia TT Status: _______________________
______
Diabetes
AGE :
HIGHEST EDUC
Itching or sores in or around vagina

Pain or burning sensation on urination
SOCIAL HISTORY
_______________ ______________
Smoking Sticks per day ___________
HIGHESST EDUC
Alcoholic beverage Amt. Per day ________

Obesity
History of domestic violence or VAW
Unpleasant relationship with partner
Treated for STIs in the past
OBSTERICAL HISTORY
Number of pregnancies:
______ Full Term ______ Premature IMPRESSION/DIAGNOSIS
OCCUPATION
______ Abortions ______ Living Children

History of Ectopic pregnancy
Hydatidiform mole (within the last 12 months)
History of Previous Deliveries
_____________ ______
Date of last delivery ___/__/_____

MUNICIPALIY
____________ ____
Type of last delivery _______________

NO. STREET
Birth Attendant in last delivery __________

Menstrual History
Last menstrual period _______________
191
PR
Past menstrual period _______________
Duration of Menstrual bleeding ________
Character of Menstrual bleeding (no. of pads)
_________________
FAMILY PLANNING HISTORY
Previously Used Method: ______________________
Reminder: Kindly refer to PHYSICIAN for any checked (√) findings for further evaluation.
MATERNAL CLIENT RECORD for Prenatal Care SIDE B
DATE MCN SERVICES GIVEN

 COMPLAINTS/COMPLICA Tetanus Toxoid
TIONS Anti-Helminthic
 MEDICAL OBSERVATION Anti-Malaria NAME OF NEXT
 PE Findings including pelvic Iron/Folate PROVIDER Follow-Up
examination FP Counseling AND Schedule
SIGNATURE
 Laboratory Counseling for Danger Signs
 OTHER IMPORTANT Referral Made
COMMENTS IF ANY
Abdominal Examination Findings
1st Trimester 2nd Trimester 3rd Trimester

1st mo 2nd mo 3rd mo 4th mo 5th mo 6th mo 7th mo 8th mo 9th mo REMARKS
Date
Fundic Height (cm)
Fetal Heart Tones
AOG
Leopold’s
L1
L2
L3
L4
Uterine Activity
USE ADDITIONAL SHEETS AS NECESSARY

 Adapted from the DOH Family Planning Service Record; updated 02/09/06.
192
MATERNAL CLIENT RECORD for Prenatal Care Family Serial NO.
Name of Client: ______________________
BIRTH AND EMERGENCY PLAN

I know that any complication can develop at any time in the course of this pregnancy, childbirth and after birth. I know
that the best place to deliver my baby is in a health facility.
I will be attended at delivery by _________________________________________________________________________

(Name of Doctor/Nurse/Midwife or others. If others, pls. specify)
I plan to deliver at _____________________________________________________________________________________
(Name and location of hospital/health center/clinic or others. If others, pls. specify)
This is a Philhealth accredited facility Yes No Distance from Residence __________________________
The estimated cost of the maternity package in this facility is PhP _____________________ (Inclusive of newborn care)
The mode of payment is _____________________________.
The available transport is ____________________________.
I have contacted ______________________, residing at _______________________________________ and with contact

(Name of Companion) (Address)
number at __________________________, to bring me to the hospital/maternity clinic/health center.
(Landline or Cellphone)
I will be accompanied by _____________________________________, who is my ______________________, residing at
(Name) (Relationship to patient)
___________________________________________________, and with contact number ___________________________.
(Address) (Landline or Cellphone)
_________________________________________, my ____________________, will take care of my children/home while
(Name of care taker) (Relationship to patient)
I am in the health facility.
My blood type is: __________________
In case of a need for blood transfusion, my possible donors are:

_____________________________________ ______________________________________________________________
(Name) (Address)
_____________________________________ ______________________________________________________________
(Name) (Address)
In case of complications, I should be referred right away to:

Contact Person: ___________________________________________________________________
Address: __________________________________________________________________________
Tel. No.: __________________________________________________________________________
The nearest maternal and newborn health facility to my residence are:
Maternal/Hospital: __________________________________ ___________________________________________

(Name of Hospital) (Address)
Newborn Hospital: ___________________________________ ___________________________________________
(Name of Hospital) (Address)
Conforme:
___________________________ __________
Signature Date
193
Annex 2.5 Department of Health
MNC Form 2 SIDE A
MATERNAL CLIENT RECORD for Postpartum and NeonatalCare Family Serial NO.
AVERAGE MONTHLY Family INCOME ______________

NAME OF SPOUSE: _____________________ __________________ ____
NAME OF CLIENT: _____________________ __________________ ____

Date of visit: ______________________
Physical Examination
Date of Delivery: ______________________ Attendant: Doctor
Outcome: Livebirths Still birth abortion Nurse
Sex: Male Female Midwife
Type of Delivery: NSD CS Others TBA/Hilot
Place of Delivery: Home Others
Health Facility AMTSL Steps:
LAST NAME
Last NAME
Government Hospital 1. Oxytocin injected w/in 1 minute
Private Hospital of delivery Yes No
Private Clinic/Birthing 2. Controlled cord contraction
Main Health Center done Yes No
BHS/Birthing Home 3. Uterine massage done Yes No
Others: Therefore, AMTSL provided: Yes No
GIVEN NAME
(Check yes if all the 3 steps were done)
GIVEN NAME
ASSESSMENT OF THE POST PARTUM MOTHER NEWBORN ASSESSMENT
Postpartum Visits Postnatal Visits

Danger Signs Danger Signs (Baby)
(Mother) w/in 24 w/in Other w/in 24 w/in Other
hrs 5-10 days visits hrs 3-5days visits
M.I.
M.I.
If breathing is >60/min or
Unconscious <30/min
Vaginal Bleeding Severe chest indrawing

____/____/________
No. of pads per day
____/____/________ _______________ ________________

Grunting
Severe abdominal Convulsions
Pain
Floppy or stiff extremities
Looks very ill Temp.>37.5 or <35.5
Bleeding from umbilical
Severe headache
stump or cut
with visual
Umbilicus draining pus or
disturbance umbilical redness
Severe difficulties of extending to skin
______
AGE :
HIGHEST EDUC
breathing More than 10 skin
pustules or swelling,
Post partum redness, or hardness of
depression skin
_______________ ______________ ____________ ___________

HIGHESST EDUC
Postpartum Visits
PelvicExam Immediate Essential Newborn
w/in 24 w/in 5-10 Other Care (ENC) Yes No
Findings
hrs days visits
1. Immediate & thorough drying
Uterus
OCCUPATION
2. Early skin to skin contact

Contracted
Relaxed 3. Timely cord clamping
Vaginal Bleeding : 4. Early initiation of breast-
feeding w/in 90 minutes
Profuse
Early ENC given (check yes if all 4
OCCUPATION
Moderate
Scanty components were provided)
Vaginal Discharge: Breastfeeding:

Color After 90 minutes but w/in twenty-four (24) hrs
_____________ _______________
MUNICIPALIY
Odor
Vaginal Laceration Postnatal Visits
Other ENC Given
1st Degree
NO. STREET
w/in 24 w/in 3-5 Other

2nd Degree hrs days visits
3rd Degree 1. Vit. K injection
If with laceration, 2. Eye prophylaxis
Sutured? 3. Referred for
Yes or No Newborn Screening
PROVINCE
If CS, bleeding Others

BARANGAY
and/or swelling
from the wound Newborn Screening Done:
Yes Date ______________ No
Date Result ____________
Supplementation: Number Given
No. of tablets given (60mcg 194
MATERNAL CLIENT RECORD for Postpartum and Neonatal Care SIDE B
DATE MCN SERVICES GIVEN

 COMPLAINTS/COMPLICAT Tetanus Toxoid
IONS Vitamin A
 MEDICAL OBSERVATION Anti-Malaria NAME OF NEXT
 Pertinent PE Findings Iron/Folate PROVIDER Follow-Up
including pelvic examination FP Counseling AND Schedule
Counseling for Danger Signs SIGNATURE
 Laboratory
 OTHER IMPORTANT Referral Made
COMMENTS IF ANY
195
Family Serial No.________
Annex 2.6 Republic of the Philippines
FAMILY PLANNING SERVICE RECORD* SIDE A

MEDICAL HISTORY PHYSICAL EXAMINATION

METHOD ACCEPTED: □ COC □ Contraceptive patch □ POP □ Injectable □ Condom □ IUD □ BTL □ VSC □ LAM □ SDM □ BBT □ Billings/Cervical Mucus/Ovulation Method
NAME OF SPOUSE: _________________ ______________ ____ ____/____/________ _________________ _________________ AVERAGE MONTHLY INCOME : ___________
NAME OF CLIENT: _________________ ______________ ____ ____/____/________ _____ ______________ ______________ _________ _________ ___________ ___________
CLIENT NO.: ____
HEENT Blood Pressure: ___ mm Weight: ____ kg/lbs
Epilepsy/Convulsion/Seizure Enlarged thyroid Pulse Rate: _____/ min (N.V. = 70 to 80/min)
Severe headache/dizziness Yellowish
Visual disturbance/ conjunctiva CONJUNCTIVA
blurring of vision Pale Yellowish
NECK
CHEST/HEART
Enlarged thyroid
Severe chest pain
Shortness of breath and easy fatigability Enlarged lymph nodes
TYPE OF ACCEPTOR:
Breast/axillary masses BREAST Right Breast Left Breast
Nipple discharges (specify if blood or pus) Mass
Systolic of 140 & above Nipple discharge
LAST NAME
LAST NAME
Diastolic of 90 & above Skin – orange peel or dimpling
Family history of CVA (strokes), hypertension asthma,
Enlarged axillary lymph nodes
rheumatic hearth disease
THORAX
PLAN MORE CHILDREN : □ Yes □ No

ABDOMEN Abnormal heart sounds/cardiac rate
Mass in the abdomen Abnormal breath sounds/respiratory rate
History of gallbladder disease ABDOMEN
□ New to the Program

History of liver disease Enlarged lever Mass
GENITAL Tenderness
GIVEN NAME
EXTREMITIES
GIVEN NAME
Mass in the uterus Intermenstrual bleeding
Vaginal discharge Postcoital bleeding Edema Varicosities
EXTREMITIES PELVIC EXAMINATION

Severe varicosities Others – (Please specify) __________________
Swelling or severe pain in the legs not related to injuries PERINEUM
UTERUS
□ Continuing User
SKIN Scars Position
M.I.
Warts
M.I.
Yellowish skin
Mid
HISTORY OF ANY OF THE FOLLOWING Reddish
Anteflexed
Smoking

Laceration
REASON FOR PRACTICING FP: _______________________________________________

Allergies VAGINA Retroflexed
Drug intake (anti-tuberculosis, anti-diabetic, anticonvulsant) Congested
Size
Bleeding tendencies (nose, gums, etc.)
Bartholin’s cyst Normal
Anemia
PREVIOUSLY USED METHOD: ___________________

Warts Small
Diabetes
Skene’s Gland Large
Discharge Mass □
OBSTERICAL HISTORY Rectocele Uterine Depth: ___cms.
Number of pregnancies:
______ Full Term ______ Premature
Cystocele (for intended IUD users)
CERVIX
_______ Abortions ______ Living Children
________ Full Term Congested ADNEXA
AGE
Date of last delivery ___/__/_____ Erosion
Mass
Type of last delivery _______________
HIGHEST EDUC
Discharge
Past menstrual period _______________ Tenderness
Polyps/cysts
Last menstrual period _______________
HIGHEST EDUC
Laceration
Duration and character Consistency
Menstrual bleeding ________________ Firm Soft
RISKS FOR VIOLENCE AGAINST WOMEN (VAW)
History of domestic violence or VAW

HISTORY OF ANY OF THE FOLLOWING Unpleasant relationship with partner
OCCUPATION NO. ST BGY MUNI PROV
Hydatidiform mole (within the last 12 months) Partner does not approve of the visit to FP clinic
Ectopic pregnancy
Partner disagrees to use FP
OCCUPATION
STI RISKS Referred to: □ DSWD □ WCPU □ NGOs

DATE/TIME ________________
With history of multiple partners □ Others (specify: ______________)

For Women:
ACKNOWLEDGEMENT:
Unusual discharge from vagina This is to certify that the Physician/Nurse/ Midwife of the
Itching or sores in or around vagina clinic has fully explained to me the different methods available in
Pain or burning sensation family planning and I freely choose the
Treated for STIs in the past ______________________ method.
For Men: _______________________ ___________
Pain or burning sensation Client Signature Date
Open sores anywhere in genital area
Pus coming from penis
Swollen testicles or penis
Treated for STIs in the past
Reminder: Kindly refer to PHYSICIAN for any checked (√) findings prior to provision of any method for further evaluation.
196
FAMILY PLANNING SERVICE RECORD
METHOD REMARKS NAME OF NEXT
TO BE  MEDICAL OBSERVATION PROVIDER SERVICE
USED/SUPPLIES  COMPLAINTS/COMPLICATIONS AND DATE
GIVEN  SERVICE RENDERED/PROCEDURES/ SIGNATURE
DATE INTERVENTIONS DONE (laboratory examination,
SERVICE METHOD/ NO. OF treatment, FP referrals, FP counseling, contraceptive
GIVEN dispensing, etc.)
BRAND UNITS
 REASONS FOR STOPPING OR CHANGING
METHOD/BRAND
 OTHER IMPORTANT COMMENTS IF ANY
DON’T LEAVE ANY BOXES BLANKS NOT FILLED-UP

* Adapted from the DOH Family Planning Service Record; updated 02/09/0
197
Annex 2.7
SUMMARY OF SERVICES RENDERED
Date Tooth Oral Temp. Perm. Sealant Exo. Consul- Others Remarks Signature
No. Prophy Filling Filling Tation (Specify)
Family Serial No. _______
Dental Health Program
Individual Treatment Record
Name
___________________________________________
__________
Surname First Name
M.I.
Date of Birth ________________________ Age ______ Sex
__________
Place of Birth
___________________________________________
__________
Address
___________________________________________
__________
Occupation
___________________________________________
__________
Parent/Guardian
___________________________________________
__________
Medical History
___________________________________________
__________
___________________________________________
__________
Oral Health Status

A. Check ( / ) if present ( X ) if absent
198
Date of Oral Examination
Dental Caries
Gingivitis/Periodontal
Disease
Debris
Calculus
Abnormal Growth
Cleft Lip/Palate
Others (supernumerary/
mesiodens, etc)
B. Indicate Number
No. of Perm. Teeth Present
No. of Perm. Sound Teeth
No. of Decayed teeth (D)
No. of Missing Teeth (M)
No. of Filled Teeth (F)
Total DMF Teeth
No. of Temp. Teeth Present
No. of Temp. Sound Teeth
No. of decayed teeth (d)
No. of filled teeth (f)
Total of Teeth
199
A. Oral Health Condition P Pontic P
Year I – Date
Year IV – Date
B. Services Monitoring Chart
55 54 53 52 51 61 62 63 64 65
55 54 53 52 51 61 62 63 64 65 Date Sealant/PF/TF/Exo
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 55 54 53 52 51 61 62 63 64 65
38
85 84 83 82 81 71 72 73 74 75
85 84 83 82 81 71 72 73 74 75
Year II – Date
55 54 53 52 51 61 62 63 64 65
Year V – Date 85 84 83 82 81 71 72 73 74 75
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 55 54 53 52 51 61 62 63 64 65 Date Sealant/PF/TF/Exo
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
28
85 84 83 82 81 71 72 73 74 75
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
38
Year III – Date
55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75
Capital letters shall be used for recording the condition of

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
permanent dentition and small letters for the status of 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
temporary dentition
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Permanent Tooth Condition Temporary Legend:

Legend: √ Sound √ S - Sealant
D Decayed D PF - Permanent Filling (composite, Am/ART)
85 84 83 82 81 71 72 73 74 75 F Filled F
TF - Temporary Filling
M Missing M
Un Unerupted Un X - Extraction
JC Jacket Crown Jc O - Others
200
Republic of the Philippines Annex 1 TB
Annex 2.8 Tuberculosis Prevention and Control Program
INDIVIDUAL TREATMENT CARD (ITC) Family Serial No.
________
TB Case Number Date the Card is Opened Region-Province/City Name of DOTS Facility
Month day year

Name of Patient Occupation Age Sex Contact Number
Address: BCG Scar

[ ] Yes [ ] No
[ ] Doubtful
Name/Relationship/Address of Contact Person Contact Number
Source of Patient: History of Anti-TB Drug Intake: [ ] No [ ] Yes No. of Household

[ ] Public [ ] Private Duration: [ ] < 1 mo. [ ] > 1 mo. contacts:
Name of Referring Physician: Specify drugs: ___________________ ( ) < 10 yrs old
When:_________________ Where: __________________Smear Status _______________ ( ) ≥ 10 yrs old
Classification of TB: Category (encircle):

[ ] Pulmonary I. 2HRZE/4HR II. 2HRZES/1HRZE/5HRE
[ ] Extra-pulmonary, specify site: ____________________ New Case 1. Relapse
1. Smear (+) 2. Treatment Failure
Type of Patient: 2. Seriously ill 3. Return After Default (RAD)
[ ] New [ ] Return After Default (RAD) 2.1. Smear (-) with extensive 4. Other (smear+/-)
[ ] Relapse [ ] Treatment failure parenchymal lesions as III. (2HRZE/4HR)
[ ] Transfer-in [ ] Other assessed by the TBDC New Case
3. Extra-pulmonary 1. Smear (-) with minimal
parenchymal lesions as
assessed by the TBDC
Sputum Examination Results/Weight Record Treatment started: month____ day____ year__________
Month Due Date Date Result Weight (kg) Treatment Outcome:

Examined
0 [ ] Cured [ ] Failed
Date:__/__/__ Date:__/__/__
2
3 [ ] Treatment Completed [ ] Defaulted
Date:__/__/__ Date:__/__/__
4 Specify:___________________
5 [ ] Died [ ] Transferred out
6 Date:__/__/__ Date:__/__/__
Cause:_______________ Specify: ___________________
>7
Chest X-ray result (If applicable): TBDC findings and recommendations:
_______________________________________________________________ _______________________________________________________________
Name of treatment partner: ________________________________________ Designation of treatment partner:_____________________________
201
Drug Intake (Intensive phase)
Doses
Cumulative
given for
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 this
Doses
given
month
Drug Intake (Continuation Phase)
Doses
Cumulative
given for
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 this
Doses
given
month
REMARKS: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
202
Annex 2.9
Republic of the Philippines Annex 3 Malaria
Malaria Prevention and Control Program
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No.

Laboratory Result
For the Health Worker Slide Number __________
PLACE PATIENT CONSULTED Microscopy RDT
Hospital RHU BHS Others Pf Pf
BMC Pv Pv
Month Day Year Pm Neg
DATE CONSULTED NMPS
Clinical Diagnosis
NAME OF PATIENT _______________________________________________________________________________________

Last Name First Name M.I.
AGE Year Month (if below 1 yr old)
SEX Male Female
PREGNANT Yes No
WEIGHT ________________ kilo/s
IP Yes, tribe _________________________ No
OCCUPATION (PATIENT)
None Farmer Logger
Fisherman Miner Others ________________________
ADDRESS _______________________________________________________________________________________
Street Brgy. Mun. Prov.
HOUSEHOLD HEAD ______________________________________________________________________________________

CHIEF COMPLAINT ______________________________________________________________________________________
Month Day Year

ONSET OF ILLNESS
MALARIA LABORATORY RESULT:
Name of the BMC/RHU/Hospital Staff __________________________________________________________________________

Name of Microscopist __________________________________________________________________________
Month Day Year
DATE SLIDE EXAMINED
Month Day Year
DATE RESULT RELEASED
DRUGS GIVEN NUMBER NUMBER NUMBER

1. Chloroquine ___ tabs 4. Coartem ___ tabs 7. Others ________ _____
2. Sulfadoxine-pyrimethamine ___ tabs 5. Quinine ___ tabs 8. None
3. Primaquine ___ tabs 6. Antibiotics ___ tabs, specify ____________________________
Month Day Year

Date Given
SUPERVISED TREATMENT ON DAY 1 Yes No

CLASSIFICATIONS: 1. Probable - Uncomplicated Severe 2. Confirmed - Uncomplicated Severe
Remark(s): ______________________________________________________________________________________________
NAME OF HEALTH WORKER/ ______________________________________________________________________

DESIGNATION Last Name First Name M.I.
203
BHW MALARIA VOLUNTEER BM MHO Hospital Staff
Annex 2.10
RHM MMC FAW PHN
REFERRED TO _________________________________________________________
REASON FOR REFERRAL ________________________________________________
Tear Here
Month Day Year
DATE RESULT RELEASED Laboratory Result
Slide Number ___________
WHO/WHERE RESULT WILL
BE SENT TO ______________________________________________________ Microscopy RDT
STREET/BARANGAY ________________________________________________ Pf Pf
HOUSEHOLD HEAD ________________________________________________ Pv Pv
Last Name First Name M.I. Pm Neg
NAME OF PATIENT _________________________________________________ NMPS
Last Name First Name M.I. Clinical Diagnosis
AGE SEX Male Female

Year Month
Remark(s): ___________________________________________________________________________________________________
REFERRED TO: ______________________________________ REFERRED BY: _________________________________________
Annex 2 Leprosy
Leprosy Prevention and Control Program
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No.:_______
Name: ___________________________________ Sex: _________ Age: ________
Present Address: ______________________________ Civil Status: ______________________
Date of Birth: _____________________________ Place of Birth: ____________________
Name & Address of Nearest Relative: _____________________________________________________
Occupation: __________________________ Contact Number: __________________
Mode of Detection: Self Reporting ( ) Referral ( ) Household Contact Exam ( ) Special Project ( )
Signs: No. of patches with loss of sensation: _______________________________________________

Enlargement/tenderness of peripheral nerve/s: Yes ( ) How many? ____ No ( )
Positive smear (if done): Yes ( ) No ( )
Classification: PB ( ) MB ( ) Date Classified: __________ Date Treatment Started: __________
Type of Case: New ( ) Relapse ( ) Return After Default ( ) Reclassified ( ) Trans – in ( )
HOUSEHOLD CONTACT EXAMINATIONS:
DATE OF EXAM/RESULT REMARKS

NAME OF HOUSEHOLD
AGE RELATIONSHIP SEX
CONTACT
Y1 Y2 Y3 Y4 Y5
204
DRUG COLLECTION CHART
GIVEN BY
DATE FOR THE REMARKS
TREATMENT (Initials)
SUPERVISED DOSE
PB MB
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Treatment Outcome:
Cured/Treatment Completed: Date: ________ Defaulted: Date: __________
Transferred Out: Date: __________________ Died: Date: _____________
205
206
Annex 2.11 Annex 4 Schistosomiasis
Schistosomiasis Prevention and Control Program

Family Serial No.______
I. GENERAL DATA:
NAME: _____________________________________ AGE: ______ SEX: ______

STATUS: Married___ Single ____ Widow/er ____ Separated _____
ADDRESS: ___________________________________CONTACT NO. ___________
II. SOCIO-ECONOMIC DATA:
1. Occupation: ________________________________________
2. Number of members in the household: ___________________
3. Sanitation & Hygiene Data:
3.1 With Sanitary toilet? Yes: _____ No: ____
3.2 With Access to safe Water Supply? Yes: ____ No: ____
III. PAST HISTORY OF EXPOSURE TO SCHISTOSOMIASIS ENDEMIC AREA?

Yes ____ No ____, If Yes pls. specify? ________________ How long? ________
1. History of past schisto infection?

Yes ____ No ____, if yes, When? _________________
2. Were you able to take the medication during that conclusive Schistosomiasis infection?
Yes ____ No ____, if yes, What meds? _________________________
IV. Chief Complaints: (please check any)
Abdominal pain __________

Bloody mucoid stool __________
Fever __________
Headache __________
Seizure __________
Others: __________
V. Vital signs & pertinent PE findings:
Wt: ____________ (kg)

BP: ____________ Pallor: _____________ Ascites: ______________
Temp: ____________ Hepatomegaly _____________ Others ______________
RR: ____________ Splenomegaly _____________
VI. Diagnosis: _______________________________________________________________
VII.
Laboratory Date Results Remarks
Examination
Stool Exam
1st
2nd
Blood Exam
Urinalysis
Others
VIII. Action Taken _______________________________________________________________
207
Annex 5 Filariasis
Annex 2.12
Filariasis Prevention and Control Program
Family Serial No.______
PERSONAL DATA
NAME: ______________________________________ AGE: ____ SEX: ____ CIVIL
STATUS:____________
ADDRESS: _______________________________________________CONTACT NUMBER:
_______________
DURATION OF STAY AT ABOVE ADDRESS: _____ BIRTH PLACE:
_________________________________
OCCUPATION: ___________________________ PLACE OF WORK:
________________________________
CLINICAL DATA
CHIEF COMPLAINT:
________________________________________________________________________
HISTORY OF PRESENT ILLNESS:

Signs and Symptoms Location Frequency Duration
FEVER
BODY MALAISE/
HEADACHE/ CHILLS:
LYMPHADENITIS
RETROGRADE/RECURRENT
LYMPHANGITIS
HISTORY OF PAST FILARIA INFECTION:

BLOOD EXAMINATION (If done: Results):
_________________________________________________
TREATMENT:
________________________________________________________________________
REACTION:
_________________________________________________________________________
FAMILY HISTORY: (Other similar case/cases in the same household)

NAME AGE SEX OCCUPATION ADDRESS
1. ___________________________ ____ ____ ______________________
______________________
2. ___________________________ ____ ____ ______________________
______________________
3. . __________________________ ____ ____ ______________________
______________________
SOCIAL HISTORY:
PREVIOUS PLACES OF RESIDENCE (Inclusive Dates)
208
1.
_______________________________________________________________________________________
_
2.
_______________________________________________________________________________________
_
PREVIOUS OCCUPATION (Inclusive Dates)

1.
_______________________________________________________________________________________
_
2.
_______________________________________________________________________________________
_
PHYSICAL EXAMINATION FINDINGS:

Weight: ________ BP: ____________ Temp:______ Cardiac Rate: ______ Resp. Rate:
___________
LYMPHADENITIS (Specify/Location):
__________________________________________________________
LYMPHANGITIS (Specify/Location):
___________________________________________________________
LYMPHEDEMA (Specify/Location):
____________________________________________________________
ELEPHANTIASIS (Specify-Leg/Scrotum/Arm/Penis/Vulva/Breast)
____________________________________
_______________________________________________________________________________________
___
MANAGEMENT:
____________________________________________________________________________
_______________________________________________________________________________________
___
Service Provider: ________________________ Date Examined: __________________
209
Annex 2.13

INDIVIDUAL TREATMENT RECORD (ITR) FOLLOW-UP FORM

For All Children Under-Five Years of Age with Health Problems under IMCI or Non-
IMCI Classification/Other Children/Adults
(To be attached to the Initial ITR of the patient)
PATIENT’S CASE SUMMARY
Patient’s Name__________________________________ Family Serial No:______

Date of Visit:_____________ Age (in months if under five years of age):________
I. Subjective Complaints(S/Sx):
Chief Complaint:
Present Illness:
Past History:
II. Objective Findings:
Vital signs: Heart Resp.

BP (if ____ Rate: _____ Rate: _____
Needed):
Temp: ____ Weight: ____ Height: _____
Physical Examination:
_________________________________________________________________________
___________________________________________________________________
______________________________________________________________________
Laboratory Results: ____________________________________________________
III. Assessment/Classification:
_________________________________________________________________________
___________________________________________________________________
______________________________________________________________________
IV. Follow-up Plan of Management: (Further Treat, Refer and Health Educate)
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________
_____________________________________
Name and Signature of Service Provider
210

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Field Health Services

FHSIS VER. 2012

Public Health Surveillance and Informatics Division

The Field Health Services Information System (FHSIS) continues to

I am proud to present this update to enhance the data quality of the

ENRIQUE A. TAYAG, MD, FPSMID, PHSAE, CESO III

Enrique A. Tayag MD, PHSAE, FPSMID, CESO III

Vito G. Roque, Jr. RMT, MD, PHSAE

Vikki Carr D. de los Reyes, MD, PHSAE

Kristine Dianne T. Toledo, RN

Francis Raize Nicholas Bautista, RN

Dr. Florencia Apale Mr. Edgardo Erce

Dr. Anthony Calibo Ms. Ruth Martinez

Dr. Manuel Calonge Engr. Joselito Riego de Dios

Dr. Anthony Cu Dr. Genesis Samonte

Ms. Frances Precilla Cuevas Engr. Roland Santiago

Dr. Marian Lynn de Laza Ms. Gloria Rodriguez

Ms. Luz Campos Engr. Ma. Elizabeth Baba

Mr. Mariano Selorio Jr. Mr. Leonardo Bautista

Ms. Genoveva Viñas Ms. Maria Angeles de Guzman

Ms. Suenia Loria Mr. Paulito Ofiasa, RN

Ms. Alma Dumasis Ms. Maria Luz dela Cuadra

Ms. Hermela Tan Ms. Delia Ramos

Ms. Lilia Mariano

Chapter 3 - FHSIS version 2012 Metadata

1.2 Objectives of FHSIS ver. 2012

1.3 Principles of FHSIS ver. 2012

1.4 Components of FHSIS ver. 2012

2.1 RECORDING TOOLS:

2.1.1 Individual Treatment Record (ITR)

DELA CRUZ, ROSE M.

2106 Rizal Avenue, Siniloan, Laguna

2.1.2 Target Client List (TCL)

2.1.3 Summary Table

2.1.4 Monthly Consolidation Table (MCT)

2.2 REPORTING TOOLS:

2.2.1 The Monthly Form

2.2.1.1 Program Report (M1)

2.2.1.2 Morbidity Report (M2)

2.2.2 The Quarterly Form

2.2.2.1 Program Report (Q1)

2.2.2.2 Morbidity Report (Q2)

2.2.3 The Annual Forms (A-BRGY, A1, A2 & A3)

2.3 RECORDING AND REPORTING TOOLS GUIDE

Locus of Recording Reporting Tools Frequency Schedule of Submission

ITR Monthly Forms Monthly every second week of succeeding

Quarterly Forms Quarterly every third week of the first month

Quarterly Reports Quarterly every fourth week of the first

2.4 REPORTING FLOW:

2.5 Target Client List for Prenatal Care

Column 6 – LAST NORMAL MENSTRUAL PERIOD /GRAVIDA-PARITY

Formula for Computing EDC:

Example: LMP = 4 14 2012

Column 10 - TETANUS TOXOID VACCINATION GIVEN – Write in this column

Tetanus Toxoid (TT) Immunization Schedule

TT2 4 weeks after first dose within the same pregnancy

TT3 6 months after TT2

TCL-PN TARGET CLIENT LIST FOR PRENATAL CARE

mm/dd/yy G-P FIRST SECOND THIRD

*Outcome: **Health Code: ***Attended by:

2.6 Target Client List for Post-Partum Care

TCL-PP CLIENT LIST FOR POSTPARTUM CARE

Code Type of Client

Outcome: Health Code: Attended by: