Performance Evaluation Form

Nurse Deployment Program

For the rating Period of January to May 2018
Name: _______________________________________ Office/Unit: MHO Camalig, Albay
Position: NDP Area of Assignment: ______ BARANGAY QUIRANGAY_______
Part I: Performance (70%)
Work Activity Performance Indicator Target Accomp.
1.       Assist in the implementation of various health programs of the LGU in accordance with the program goals of the DOH.
1.1. Safe Motherhood program
a.            Track and assist new pregnant mothers in the formulation of  their birth  ·         No. of new pregnant mothers tracked and assisted in formulating birth 
plans plan

b.            Track and provided prenatal services to prenatal defaulters ·         No. of prenatal defaulters tracked & provided with prenatal services

c.             Provide vaccination of tetanus toxoid to pregnant women  ·         No. of pregnant women vaccinated with tetanus toxoid
d.            Counsel pregnant mothers on newborn screening ·         No. of pregnant mothers counseled on newborn screening
e.             Assist in the general operations of  the birthing facility ·         No. of duty days in the birthing facility
f.             Provide post partum care to mothers ·         No. of post partum mothers assisted
·         No. of post partum defaulters tracked and provided with post partum 
g.             Track and provide post partum care to defaulters
care

h.            Provide IEC/advocacy activities on safe motherhood, oral health, FP,  ·         No. of IEC/advocacy activities on safe motherhood, oral health, FP, 
breast feeding, adolescent health, etc. breast feeding,adolescent health, etc provided.

1.2. National Immunization Program

·         No. of age appropriate  children  provided/assisted with routine 
a.            Assist/ Provide routine immunization to age-appropriate children
immunization
b.            Track and provide appropriate  immunization to defaulters ·         No. of  defaulters tracked and given appropriate immunization
c.             Provide MR/TD to Grades 1/7 during the school-based immunization ·         No. of Grades 1/7 children provided with MR/TD during SBI
d.            Refer to supervisor  cases of  adverse events following immunization 
·         No. of AEFI cases referred to supervisor
(AEFI) 
1.3. Nutrition and Integrated Helminth Control Program
a.     Assist in the nutritional assessment of children (0-59 mos.) ·         No. of children (0-59) assisted for nutritional assessment
b.     Assist in providing Vit A to  children (6-59 mos)  ·         No. of children (6-59 mos) provided with Vit A
c.     Assist/provide deworming to children (1-4 yrs) ·         No. of children (1-4 y/o) given deworming meds
d.     Assist/provide deworming meds to school-based children (5-12 y/o) and  ·         No. of school-based children and special population given deworming 
special population meds

e.     Refer adverse events following deworming  to appropriate  health facility ·         No. of AEFD cases referred to appropriate health facility
1.4. Adolescent Health Program
a.            Refer pregnant teenagers to a hospital facility ·         No. of teenage pregnant mothers referred to a hospital facility
1.5. Family Planning Program
a.            Provide counseling services to couples ·         No. of couples provided with FP counseling 
b.            Provide modern FP commodities (incl. resupply) for natural and artificial 
methods ·         No. of clients provided with modern FP commodities (incl. resupply)

Work Activity Performance Indicator Target Accomp.

1.5. Family Planning Program
c.             Track FP Defaulters ·         Number of FP Defaulters Tracked.
d.            Identify and Provide FP services to WRA/ Couple with unmet needs ·         Number of Couples with Unmet needs provided FP services.
1.6. National TB Control Program
a.            Refer presumptive TB cases to PHN/Dr.  ·         No. of presumptive TB cases referred to PHN/Dr.
b.            Follow-up TB defaulters ·         No. of TB defaulters followed-up
1.1. Nat’l. HIV/AIDS/STI Prevention & Control Program

·         No. of advocacy sessions conducted  among persons with high risks 
a.            Advocate for STI/HIV Testing among persons with high risk behaviors
behaviors 
b.            Refer persons with high risk behaviors to social hygiene clinics for FREE  ·         No. of persons with high risks behaviors referred to social hygiene 
STI/HIV testing. clinics for free STI/HIV testing.
1.2. Rabies Prevention and Control Program

·         No. of animal bite cases provided with first aid and referred to 
a.            Provide first aid and refer animal bite cases to the RHU/ABTC
RHU/ABTC

b.            Conduct  IEC/advocacy activities on responsible pet ownership  and  ·         No. of IEC activities conducted  on responsible pet ownership & rabies 
rabies prevention & control prevention & control
1.3. Health Emergency Preparedness Program

a.            Identify barangays  with Health Emergency Preparedness Plan ·         No. of barangays identified with Health Emergency Preparedness plan

b.            Identify barangays with organized and functional Barangay Health  ·         No. of barangays identified with organized & functional Barangay 
Emergency Response Team (BHERT) Health Emergency Response Teams

1.4. Lifestyle Related Diseases

a.            Assess, treat  and refer  individuals (25y/o & above) with hypertension ·         No. of individuals with hypertension  assessed, treated and referred
b.            Assess, treat  and refer  individuals (25y/o & above) with diabetes 
mellitus ·         No. of individuals with diabetes mellitus  assessed, treated and referred

c.             Assist/facilitate organization of hypertension clubs ·         No. of hypertension clubs organized/facilitated/assisted
d.            Assist/facilitate organization of  diabetes  clubs ·         No. of  diabetes  clubs organized/facilitated/assisted

1.5. Health and Wellness Program

a.            Provide, assist Senior Citizens to avail medical services ·         No. of senior citizens assisted to avail medical services

b.            Provide, assist persons with disabilities  to avail medical services ·         No. of persons with disabilities  assisted to avail medical services

1.6. National Tobacco Control Program

a.            Conduct anti-smoking advocacy activities ·         No. of anti-smoking advocacy activities conducted

·         No. of current smokers  identified& referred to Smoking Cessation 
b.            Identify and refer current smokers to Smoking Cessation Clinic
Clinic 

Work Activity Performance Indicator Target Accomp.

1.7. National Voluntary Blood Services Program

a.            Promote and recruit non-remunerated voluntary blood donors ·         No. of non-remunerated blood donors recruited

b.            Provide assistance during mass blood donation activities. ·         No. of MBDs assisted

1.8. Primary Eye Care Program

a.            Assist/identify and refer individuals with low visions ·         No. of individuals with low vision  identified and referred

1.9. Local Health Systems Development

a.            Conduct community profiling and assessment (Form 02-LHSC) ·         No. of community profiling done

b.            Attend /provide TA during Barangay Health Board meetings ·         No. of Barangay Health Board meetings attended

c.             Facilitate referrals of clients to appropriate facility included in the Service 
·         No. of clients referred to the SDN
Delivery Network (SDN)

1.10. KP/Hi5 implementation

a.            Supervise and monitor CHTs; validate CHT columnar report  ·         No. of CHTs supervised/monitored/ provided with TA

b.            Conduct profiling of  NHTS /non NHTS families ·         No. of NHTs & non-NHTS families profiled.

2. Analysis & Submission of required reports

2.1.     Gather and submit Hi5 reports to supervisor ·         No. of reports submitted to supervisors:

2.2. Conduct DQC and submit report to TL/MHO o    Hi5 monthly report

2.3. Submit other reports as may be required  o    DQC Summary report

o    Others

                                                                                                                                                                 Total:    ___________________
                                                                                                                              Divide by the number of entries:___________________
                                                                                                                              Average Point Score (APS):    ____________________
                                                                                        Total Weighted Average Score (TWAS) x 70%:___________________________

Ratee: __________________________________ Rater:  ______GISELA M. BUIZA, RN_______ Date: ________________

Position: _____ NDP-Nurse II______________ Position: _________PHN______________

Part II: Behavioral (30%) Rating

1.      COURTESY

2.      HUMAN RELATIONS

3.      INTEGRITY

4.      STRESS TOLERANCE

5.      INITIATIVE / RESOURCEFULNESS

6.      COMPLIANCE TO OFFICE RULES AND REGULATIONS

7.      PUNCTUALITY AND ATTENDANCE

Total Point Score (TPS)

Divide by Entries

Average Point Score

Total Weighted Average Score (TWAS) x 30%
 Total Overall Score (TWAS Part I + TWAS Part II:  _________________________________

_______________________________________
Final Numerical Rating: 
__________________________
Adjectival Rating:

COMMENTS AND RECOMMENDATIONS BY THE IMMEDIATE SUPERVISOR

____________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Ratee: __________________________ Rater: Gisela M. Buiza, RN Ma. Crispa L. Florece, MD

         Signature over printed name                                    Signature over printed name                                     Confirmed by Next Higher Supervisor

Position: ___NDP-Nurse II Position:    ____PHN__________ Municipal Health Officer

Date: ________________________ Date: __________________                        Date:  ___________________
Rating
Rating
Rating
___________
_________________________________________________________________________________________________________________________________________________
 ACCOMPLISHMENT REPORT
NURSE DEPLOYMENT PROGRAM
FOR THE MONTH OF ______________________

Name: DENNIS M. MABUNGA Office/Unit: RHU CAMA

Position: NDP-NURSE II Area of Assignment: BH
Brgy: COTMON
Work Activity Performance Indicator TP: 2,642
T
1.       Assist in the implementation of various health programs of the LGU in accordance with the program goals of the DOH.
1.1. Safe Motherhood program
a.             Track and assist new 
pregnant mothers in the  ·         No. of new pregnant mothers tracked 
formulation of  their birth  and assisted in formulating birth plan
b.             Track and provided 
plans ·         No. of prenatal defaulters tracked & 
prenatal services to prenatal 
provided with prenatal services
defaulters
c.             Provide vaccination 
·         No. of pregnant women vaccinated with 
of tetanus toxoid to pregnant 
tetanus toxoid
women 
d.            Counsel pregnant 
·         No. of pregnant mothers counseled on 
mothers on newborn 
newborn screening
screening
e.             Assist in the general 
operations of  the birthing  ·         No. of duty days in the birthing facility
facility
f.              Provide post partum 
care to mothers ·         No. of post partum mothers assisted
g.             Track and provide  ·         No. of post partum defaulters tracked 
post partum care to defaulters
h.            Provide IEC/advocacy  and provided with post partum care
activities on safe  ·         No. of IEC/advocacy activities on safe 
motherhood, oral health, FP,  motherhood, oral health, FP, breast 
breast feeding, adolescent  feeding,adolescent health, etc provided.
health, etc.
1.2. National Immunization Program
a.            Assist/ Provide 
routine immunization to age- ·         No. of age appropriate  children  
appropriate children provided/assisted with routine immunization
b.            Track and provide 
·         No. of  defaulters tracked and given 
appropriate  immunization to 
appropriate immunization
defaulters
c.             Provide MR/TD to 
·         No. of Grades 1/7 children provided 
Grades 1/7 during the school-
d.             Refer to supervisor   with MR/TD during SBI
based immunization
cases of  adverse events 
following immunization  ·         No. of AEFI cases referred to supervisor
(AEFI) 
ACCOMPLISHMENT REPORT
NURSE DEPLOYMENT PROGRAM
FOR THE MONTH OF ______________________

Name: DENNIS M. MABUNGA Office/Unit: RHU CAMA

Position: NDP-NURSE II Area of Assignment: BH
Brgy: COTMON
Work Activity Performance Indicator TP: 2,642
T
1.3. Nutrition and Integrated
Helminth Control Program
 a.     Assist in the nutritional  ·         No. of children (0-59) assisted for 
assessment of children (0-59 mos.) nutritional assessment
b.     Assist in providing Vit A to   ·         No. of children (6-59 mos) provided 
children (6-59 mos)  with Vit A
c.     Assist/provide deworming to  ·         No. of children (1-4 y/o) given 
children (1-4 yrs) deworming meds
d.     Assist/provide deworming meds 
·         No. of school-based children and 
to school-based children (5-12 y/o) 
special population given deworming meds
and special population
e.     Refer adverse events following 
·         No. of AEFD cases referred to 
deworming  to appropriate  health 
facility appropriate health facility

1.4. Adolescent Health Program

a.            Refer pregnant  ·         No. of teenage pregnant mothers 
teenagers to a hospital facility referred to a hospital facility

1.5. Family Planning Program

a.            Provide counseling  ·         No. of couples provided with FP 
b.             Provide modern FP 
services to couples counseling 
commodities (incl. resupply)  ·         No. of clients provided with modern FP 
for natural and artificial  commodities (incl. resupply)
methods
c.             Track FP Defaulters ·         Number of FP Defaulters Tracked.
d.            Identify and Provide 
·         Number of Couples with Unmet needs 
FP services to WRA/ Couple 
provided FP services.
with unmet needs
1.6. National TB Control Program
a.            Refer presumptive TB  ·         No. of presumptive TB cases referred to 
cases to PHN/Dr.  PHN/Dr.
b.            Follow-up TB 
·         No. of TB defaulters followed-up
defaulters
ACCOMPLISHMENT REPORT
NURSE DEPLOYMENT PROGRAM
FOR THE MONTH OF ______________________

Name: DENNIS M. MABUNGA Office/Unit: RHU CAMA

Position: NDP-NURSE II Area of Assignment: BH
Brgy: COTMON
Work Activity Performance Indicator TP: 2,642
T
1.1. Nat’l. HIV/AIDS/STI Prevention
& Control Program
a.            Advocate for STI/HIV Testing among  ·         No. of advocacy sessions conducted  
persons with high risk behaviors among persons with high risks behaviors 
b.            Refer persons with high risk behaviors  ·         No. of persons with high risks behaviors 
to social hygiene clinics for FREE STI/HIV  referred to social hygiene clinics for free 
testing. STI/HIV testing.

1.2. Rabies Prevention and Control

Program
a.             Provide first aid and refer animal bite  ·         No. of animal bite cases provided with 
cases to the RHU/ABTC first aid and referred to RHU/ABTC
b.            Conduct  IEC/advocacy activities on  ·         No. of IEC activities conducted  on 
responsible pet ownership  and rabies  responsible pet ownership & rabies 
prevention & control prevention & control
 1.3. Health Emergency Preparedness
Program
a.             Identify barangays  with Health  ·         No. of barangays identified with Health 
Emergency Preparedness Plan Emergency Preparedness plan
b.            Identify barangays with organized and  ·         No. of barangays identified with 
functional Barangay Health Emergency  organized & functional Barangay Health 
Response Team (BHERT) Emergency Response Teams

1.4. Lifestyle Related Diseases

a.            Assess, treat  and refer  individuals  ·         No. of individuals with hypertension  
(25y/o & above) with hypertension assessed, treated and referred
b.            Assess, treat  and refer  individuals  ·         No. of individuals with diabetes 
(25y/o & above) with diabetes mellitus mellitus  assessed, treated and referred
c.             Assist/facilitate organization of  ·         No. of hypertension clubs 
hypertension clubs organized/facilitated/assisted
d.            Assist/facilitate organization of   ·         No. of  diabetes  clubs 
diabetes  clubs organized/facilitated/assisted

ACCOMPLISHMENT REPORT
NURSE DEPLOYMENT PROGRAM
FOR THE MONTH OF ______________________

Name: DENNIS M. MABUNGA Office/Unit: RHU CAMA

Position: NDP-NURSE II Area of Assignment: BH
Brgy: COTMON
Work Activity Performance Indicator TP: 2,642
T
1.5. Health and Wellness Program
a.            Provide, assist Senior 
·         No. of senior citizens assisted to avail 
Citizens to avail medical 
medical services
services
b.            Provide, assist persons 
·         No. of persons with disabilities  assisted 
with disabilities  to avail 
medical services to avail medical services

1.6. National Tobacco Control

Program a.            Conduct anti-smoking 
·         No. of anti-smoking advocacy activities 
advocacy activities conducted
b.            Identify and refer 
·         No. of current smokers  identified& 
current smokers to Smoking 
referred to Smoking Cessation Clinic 
Cessation Clinic

1.7. National Voluntary Blood Services

Program a.            Promote and recruit 
·         No. of non-remunerated blood donors 
non-remunerated voluntary 
recruited
blood donors
b.            Provide assistance 
during mass blood donation  ·         No. of MBDs assisted
activities.

1.8. Primary Eye Care Program

a.            Assist/identify and 
·         No. of individuals with low vision  
refer individuals with low 
identified and referred
visions
 1.9. Local Health Systems
Developmenta.            Conduct community 
profiling and assessment  ·         No. of community profiling done
(Form 02-LHSC)
b.             Attend /provide TA 
·         No. of Barangay Health Board meetings 
during Barangay Health 
c.              Facilitate referrals of  attended
Board meetings
clients to appropriate facility 
·         No. of clients referred to the SDN
included in the Service 
Delivery Network (SDN)
ACCOMPLISHMENT REPORT
NURSE DEPLOYMENT PROGRAM
FOR THE MONTH OF ______________________

Name: DENNIS M. MABUNGA Office/Unit: RHU CAMA

Position: NDP-NURSE II Area of Assignment: BH
Brgy: COTMON
Work Activity Performance Indicator TP: 2,642
T
1.10. KP/Hi5 implementation
a.            Supervise and monitor 
·         No. of CHTs supervised/monitored/ 
CHTs; validate CHT 
provided with TA
columnar report 
b.            Conduct profiling of   ·         No. of NHTs & non-NHTS families 
NHTS /non NHTS families profiled.

2. Analysis & Submission of required reports

2.1.     Gather and submit Hi5 reports to  ·         No. of reports submitted to supervisors:
supervisor
2.2. Conduct DQC and submit report to  o    Hi5 monthly report
TL/MHO
2.3. Submit other reports as may be  o    DQC Summary report
required  o    Others

Prepared and submitted by : ( NDP) Supervisor : Approved by: (MHO/C

________________________________________ __________________________________ ____________________

DENNIS M. MABUNGA, RN GISELA M. BUIZA, RN MA. CRISPA L.
HMENT REPORT
YMENT PROGRAM
_____________________

Office/Unit: RHU CAMALIG

Area of Assignment: BHS TAPLACON
Brgy: COTMON Brgy: TAPLACON Brgy: TALOTO Brgy: MABUNGA
TP: 2,642 TP: 1,267 TP: 1,094 TP: 107
P % T P % T P % T P %
program goals of the DOH.

HMENT REPORT
YMENT PROGRAM
_____________________

Office/Unit: RHU CAMALIG

Area of Assignment: BHS TAPLACON
Brgy: COTMON Brgy: TAPLACON Brgy: TALOTO Brgy: MABUNGA
TP: 2,642 TP: 1,267 TP: 1,094 TP: 107
P % T P % T P % T P %
HMENT REPORT
YMENT PROGRAM
_____________________

Office/Unit: RHU CAMALIG

Area of Assignment: BHS TAPLACON
Brgy: COTMON Brgy: TAPLACON Brgy: TALOTO Brgy: MABUNGA
TP: 2,642 TP: 1,267 TP: 1,094 TP: 107
P % T P % T P % T P %
HMENT REPORT
YMENT PROGRAM
_____________________

Office/Unit: RHU CAMALIG

Area of Assignment: BHS TAPLACON
Brgy: COTMON Brgy: TAPLACON Brgy: TALOTO Brgy: MABUNGA
TP: 2,642 TP: 1,267 TP: 1,094 TP: 107
P % T P % T P % T P %
HMENT REPORT
YMENT PROGRAM
_____________________

Office/Unit: RHU CAMALIG

Area of Assignment: BHS TAPLACON
Brgy: COTMON Brgy: TAPLACON Brgy: TALOTO Brgy: MABUNGA
TP: 2,642 TP: 1,267 TP: 1,094 TP: 107
P % T P % T P % T P %

Approved by: (MHO/CHO) Noted by: (DMO IV)

___________________________________ _____________________________________
MA. CRISPA L. FLORECE, MD DIVINA B. DAWAL, RN