Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

REGION _________
FIELD OFFICE____________

QUARTERLY PERFORMANCE REPORT ON COMPANY LEVEL

FAMILY WELFARE PROGRAM
(Art. 134 Labor Code; D. O. No. 56-03)

Reporting period: _____________________________

I. COMPANY PROFILE

1. Name of company : ___________________________________________________

2. Company address : ___________________________________________________

___________________________________________________
3. Total work force at the end
of the reporting period : Male _______ Female _______

4. Type of Industry : ___________________________________________________

5. Contact details : Tel nos.: ________________ Fax no.: _________________

Email: _________________ Website:_________________

Does the company have a union? Yes No Pending

Percentage of membership against

Name of Union Affiliation (if any)
total number of workforce
1.
2.

Does the CBA have a Family Welfare/Family Planning provision? Yes No Pending

If yes, kindly state the provision (or attached a copy):

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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II. PROGRAM ORGANIZATIONAL SET-UP

1. Organization of Family Welfare Committee (FWC)

_____ Organized and functioning

_____ Organized but inactive
_____ Not yet organized

2. Type of Family Welfare Committee1: _____ Integrated _____ Stand Alone

3. Number of committee meeting held during reporting period:__________________________________________

4. FWC sub committees organized based on the 10 dimensions:

Committee Name of Committee Head and Position

(Please use extra sheets of paper for additional information)

III. FAMILY WELFARE PROGRAMS AND ACTIVITIES

Program Dimension INTERNAL SUPPORT EXTERNAL SUPPORT

Plant level activities No. of DOLE activities DOH activities Other
organized/conducted participants organized/ organized/ Government/
during the reporting period conducted conducted NGOs activities
during the during the organized/
reporting period reporting period conducted
during the
reporting period
Mandatory Activities

1. Family Planning/
Reproductive Health
and Responsible
Parenthood

2. Gender Equality
Orientation on
Sexual
Harassment and
creation of CODI

1
Type of FWC: Intergrated if FWC is part of LMC/Union or other organization and Stand Alone if it is the
only plant level welfare committee organized.

2
Highly Recommended
Activities:

3. Education

4. Nutrition

5. Medical Health

Other FWP Activities:

6. Values Formation

7. Livelihood and
Cooperative

8. Sports and Leisure

9. Housing

10. Transportation

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IV. FAMILY PLANNING AND MATERNAL AND CHILD HEALTH PROGRAM IN THE WORKPLACE

FP and MCH Service

A. Family Planning Services Number
1. No. of employees Counseled on FP (through GATHER approach)
a. No. of males
b. No. of females
3. No. of FP users
FP Method Current User Acceptors Dropout Current User
(Begin Mo.) New Other (End Mo.)
a. Pills
b. Condoms
c. Injectables
d. IUD
e. BTL
f. NSV
g. LAM
h. SDM Beads
i. Contraceptive patch
j. Other (specify)

TOTAL
4. No. of employees referred for FP services and provided the services for which they were referred
FP METHOD No. of Employees referred for No. of Employees provided the
FP Services services for which they were
referred
Public Sector Private Sector Public Sector Private Sector
a. FP Counseling
b. Pills
c. Condoms
d. Injectables
e. IUD
f. BTL
g. NSV
h. LAM
i. SDM Beads
j. Contraceptive patch
k. Other (specify)

TOTAL
FP products dispensed (for companies dispensing Products) Number (by units)
a. Pills (cycles
b. Injectables (vials)
c. Condoms (pcs.)
d. IUD (pcs.)
e. SDM Beads (pcs.)
f. Contraceptive Patch (pcs.)

TOTAL

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B. Maternal and Child Health Services (MCH)
1. No. of employees provided services on-site//referral on the following MCH services:
On-site Service Referral
a. Pregnant women with 4 or more Prenatal visits
b. Pregnant women given 2 doses of Tetanus Toxoid
c. Pregnant women given TT2 plus
d. Birth & emergency plan
e. Nutrition information for pregnant and lactating women
f. Breastfeeding counseling
g. Information on importance of infant immunization
h. Other MCH services
(specify: ________________________________)

TOTAL
2. Exclusive Breastfeeding (6 mos) No. of employees
a.. No. of employees who are exclusively breastfeeding (6 mos.) using the workplace lactating
station

C. In the provision of FP services, do you follow the principles of informed choice? ____Yes _____No

Number of Products Official Receipt Number

Purchased or Delivery Receipt
D. FP Product Purchased Brand Name (by unit) Number

a. Pill (cycles)

b. Condoms (pieces)

c. Injectables (vials)

d. IUD (pieces)

e. SDM (pieces)

f. Contraceptive Patch (pieces)

g. Others (specify)

TOTAL

F. MCH Products Purchased

a. Iron (pieces)

b. Folate (pieces)

c. Vitamin A (pieces)
d. Tetanus Toxoid Injection (vials)

TOTAL

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V. INTERNAL SUPPORT TO THE COMPANYS FWP PROGRAM

1. On Company Policy:

FAMILY WELFARE PROGRAM DIMENSION STATUS OF POLICY

(INTEGRATED OR STAND ALONE)
a. Family Planning and Maternal & Child Health

b. Other FWP Dimension (Specify)

c. Other FWP Dimension (Specify)

d. Other FWP Dimension (Specify)

2. Family Welfare Program Budget Allocation: Total Budget Allocation for the year: Php _____________________

VI. EXTERNAL SUPPORT TO THE COMPANYS FWP PROGRAM

Monitoring visits to the company by DOLE, DOH and PHO during the reporting period as the case maybe. (Please
indicate the dates and result/findings/technical assistance provided)

_______________________________________________________________________________________________

VII. TECHNICAL ASSISTANCE NEEDED (please specify)

Setting up of Family Welfare Program _____________________________________________________________

Trainings on Family Welfare Dimension ____________________________________________________________

IEC Materials _________________________________________________________________________________

VIII. ISSUES/CONCERNS:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

IX. REPORTING DETAILS

Reports prepared by: Approved by FWC Chairman:

Name : __________________________________ Name : __________________________________

Position : __________________________________ Position : __________________________________

Signature : __________________________________ Signature : __________________________________

Attested by the HR Manager/General Manager

Name : __________________________________ Date: __________________________________

Signature : __________________________________