CHT TRAINING/DEPLOYMENT STATUS REPORT

No. of CHT Partners Target # Actual trained MUNICIPALITY of CCT number (excluding mgt.) CCT BARANGAYS families of CHTs

RNHeals Trained

Number Number of of HHs CHT assigned partners Date of to CHT deployed deployment

% of partners deployed

Number of CCT % CCT families families covered covered Number of families No. with with NHIP Family IDs Health (validated) Profile

Number of CCT Families Covered

Number With Family Health Use Plan (H

Form 2A

Form 2B

(0-28 days) (29 days to Form 2C Newborn 11 mos) (12 mos to Infant 59 mos.) Under-5 BANOEN CAYUS LAMAG TUBTUBA LEGLEG POB. MALIDEG NAMITPIT PATIACAN PATUNGCALEO SUAGAYAN QUIRINO

Reported by: ______________________________

Name and Signature ________________________ Date Reported

er of CCT Families Covered

Number With Family Health Use Plan (HUP)

Form 2D
Prenatal

Form 2E
Postpartum

Form 2F Form 2G
Family Planning Chronic cough 5 yrs and above

Form 1: CHT Mobilization Report CHD: Ilocos Region Province: Ilocos Sur Date Covered: _______________
Number of Households (B) CHT Targets (C)

Actual Number of CHTs Mobilized (D) No. of CHTeams Trained 1 1 1 1 1 1 2 1 1 10 No. of CHT Partners Trained 4 6 5 7 7 7 8 7 5 56 No. of CHT Partners Deployed 4 6 5 7 7 7 8 6 5 55

Barangays (A)

NHTS* (1)

CCT *

Target No. Target No. of of CHT (2) CHTeams* Partners* (3) (4) 1 1 1 1 1 1 2 1 1 10 4 6 5 7 7 7 8 7 5 56

No. of No. of CCT No. of CCT RNHeals HHs Explanation of Variance: Column F compared HH Visited Trained on Assigned to to Column G (H) by CHT (G) CHT (E) CHT (F)

BANOEN CAYUS LAMAG TUBTUBA LEGLEG POB. MALIDEG NAMITPIT PATIACAN PATUNGCALEO SUAGAYAN QUIRINO

53 40 65 89 91 80 87 135 70 712

43 29 55 83 68 58 77 112 52 582

43

43 29 55 83 73 58 77 112 52 582

1 1 2 1 1 1 1 1 9

29 55 83 73 58 77 112 52 582

Reported by: ______________________________

Name and Signature ________________________ Date Reported

Form 2A: CHT HOME VISITS REPORT CHD: Ilocos Region Province: Ilocos Sur Date Covered: _____________________

Barangays

Number of Number of CCT HH CCT Family with with Health Use PhilHealth ID Plan Pregnant Women Number of Seen and Referred Under 5 Senior Newborn Children Citicens

Number of Households Number of Number of Maternal Neonatal Deaths Deaths With Risk Factor(s) for TB Malaria NCD

Current Modern FP Users

PWDs

Men

Women

With Access to Safe Water

With Sanitary Toilet Facilities

BANOEN CAYUS LAMAG TUBTUBA LEGLEG POB. MALIDEG NAMITPIT PATIACAN PATUNGCALEO SUAGAYAN QUIRINO

Reported by: ______________________________

Name and Signature ___________________________ Date Reported

Form 2B: NUMBER OF FP USERS BY METHOD CHD: Ilocos Region Province: Ilocos Sur Date Covered: _______________
Traditional Methods MEN Men (Withdrawal) Barangay
BANOEN CAYUS LAMAG TUBTUBA LEGLEG POB. MALIDEG NAMITPIT PATIACAN PATUNGCALEO SUAGAYAN QUIRINO

Modern Methods WOMEN Cervical Mucus Condom Vasectomy 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Symptothermal

Women (Calendar)

Basal Body Temperature

SDM/Cycle Beads LAM 0 0 0 0 0 0 0 0 0 0 0 0 0 3 1 2 1 0 1 8 0 0 0 0 10 0 0 0 0 10

Pills 1 0 0 0 12 14 0 0 1 28

Injectibles/ DMPA 5 0 0 0 2 8 0 0 0 15

IUD 0 0 0 0 3 0 0 6 0 9

Bilateral Tubal Ligation 0 0 0 0 1 8 1 0 0 10

0 0 0 0 0 15 0 0 0 15

11 1 0 0 10 0 0 0 0 22

0 0 0 0 0 0 0 0 0 0

Reported by: ______________________________

Name and Signature ________________________ Date Reported