MONTHLY NEWBORN SCREENING CENSUS

REPORT FORM

Instructions: 1. Please fill out necessary information CORRECTLY and COMPLETELY.

2. Use black or blue ball point pen only. Do NOT fill this form with pencil.
3. Write as CLEARLY as possible. Use a pen with a thinnest possible tip.
4. Do NOT overwrite in case of a mistake. Just strikethrough the word and write necessary
corrections and initials

NBS Health Facility CODE Province/City

COMPLETE Name of Facility

Government Hospital Private Hospital

Type of Health Facility Lying-in Clinic Health Center

(Please tick appropriate box )
Others (please specify) __________________________

COMPLETE Address

Name of NBS Coordinator

Contact Numbers _ _ _ _-_ _ _-_ _ _ _ Fax Numbers _ _ _ _-_ _ _-_ _ _ _

E-mail Address @

Name of Assistant NBS Coordinator

Contact Numbers _ _ _ _-_ _ _-_ _ _ _

E-mail Address @
____ Quarter of 20____
Newborn Screened
Number of
Number of
Number of Number of Number of Number of % of NB Screened Patients Who
MONTH Deliveries Live Births Dissents Referred Screened In-Borns Availed PHIC
Neonatal
In-Born # of Live Births
Outborn Deaths
NBS Package
x 100

______________________________________________________________ _________________________
SIGNATURE OVER PRINTED NAME OF NSF COORDINATOR DATE SIGNED

The accomplished report may be sent through courier, fax or e-mail. Kindly address to:
NOTE: The submission schedule will be as follows
Date of RD Leonita P. Gorgolon, MD, MHA, MCHM, CEO VI
Monthly Census Reports
Submission Attention: Janet T. Miclat, MD
January, February, March Apr 15 Phoebe Queen A. Pamintuan, RN/ Madeline Gayle T. Luzung, RN
April, May, June Jul 15 Department of Health - Regional Office 3
July, August, September Oct 15 Diosdado Macapagal Government Center
October, November, December Jan 15 Maimpis, City of San Fernando, Pampanga

Telephone: (045) 861-3428 E-mail Address: nbs.dohro3@gmail.com

Fax Number: (045)-861-3117 Kindly follow format for the subject: FACILITY CODE AND NAME OF THE FACILITY/HOSPITAL(all caps) and
0942-978-0457 quarter (ex. 1234 OSPITAL NG PILAR 4th Quarter)
0956-736-4450