ESSENTIAL DATA COLLECTION TOOL LGU ________________________________ Date collected: _____________

INFORMAL LAB WORKER (ILW)

Municipality # of ILWs No. of LWs No. of RSS No. of Population # of RSS # Presumptive TB smeared in RSS #P
trained functional to installed Bgys Covered by functional (Source: Lab Register)
date Covered RSS to date Y1 Y2 Y3 Y4 Y5 Y1 Y2

Note: Y1 (Oct 2012-September 2013) Y2 (Oct 2013-September 2014) Y3 (Oct 2014-September 2015) Y4 (Oct 2015-
September 2016) Y5 (Oct 2016-September 2017)

BUDGET UTILIZATION

With Approved TB Amount of resources allocated as Did LGU access and utilize the allocated Proof of Utilization (e.g.
Ordinance? Y/N per ordinance (in Pesos) resources as per ordinance? (Y/N) RIV)

Note: Please bring a Xerox of the Approved TB ordinance or TB CAP and a photocopy of the proof of utilization of the budget allocated in
the TB ordinance (RIV) if utilized.

PHILHEALTH ACCREDITATION

PhilHealth Accreditation Is there a Claims Filing for DOTS Utilization of DOTS Reimbursements
trust fund Reimbursements
Is the If not PHIC accredited, state account Does the LGU Total Does the LGU If Yes, check which items below was the
facility the reason why created File Claims for amount of Utilize DOTS reimbursement used.
PhilHealt for TB DOTS claims Reimburseme
Incentive Facility Incentiv Operation Other
h DOTS Reimburseme payment nt? Y/N
s to Improvem e to al Costs s
accredite benefit nts? Y/N todate
Health ent Referrin (drugs,
d? Y/N package?
Workers g reagents,
Y/N
Physicia etc.)
n
Note: Please bring a photocopy of the proof of amount received from PhilHealth per year (2015-2016) and proof on the use of the
Philhealth reimbursement received.