Data Collection Tool

Module 1.
Data Collection Form at the RHU/MHC

Module 1.a MONTHLY Health Sector Performance Monitoring and Evaluation
For the Month of: __________________________
Name of PHA : ________________________________________ Name of Municipality/City : ________________________________________
Performance Indicator Instructions/Guide Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Annual
Item A. Get the total PSA projected population of your LGU.
Item B. Get the total number of deliveries in your LGU for the given
month. Add cumulatively on an annual basis.
Indicator 1. 1.1 Based on the FHSIS Monthly Report, get the total number
of children fully immunized for the month. Add cumulatively on
an annual basis.
Total Projected
Population
Total Number
Indicator 2. of Deliveries 2.1 Based on the FHSIS Monthly Report, get the total number
of pregnant women who had 4 or more prenatal visits for the
month. Add cumulatively on an annual basis.
Total no. of fully immunized

children
of SBA deliveries for the month. Add cumulatively on an
Total no. of pregnant annual basis.
women with 4 or more prenatal visits
% FIC
of deliveries in health care facility for the month. Add
cumulatively on an annual basis.
Total no. of deliveries
attended by a skilled health
professional
% with 4
or more prenatal visits
Total no. of
Indicator 5. 5.1 Based on the LGU FHSIS Monthly Report, get the total
number of postpartum women with at least 2 postpartum visits
for the month. Add cumulatively on an annual basis.
of all the current users of modern FP method for the month.
Total no. of postpartum women For the annual total number of all the current users of modern
with at least 2 PP visits FP method, copy the December data and place this under the
"Annual" Column.
Total no. of WRA who are Module 1. Data Collection Form at the RHU/MHC
current users of modern FP method
For the Month of: __________________________
Name of PHA : ________________________________________ Name of Municipality/City : ________________________________________
Performance Indicator Instructions/Guide Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Annual
Indicator 7. a. Modern FP Unmet Need Among Generral Population
7.1 Based on the updated list of the RHU/POPCOM on FP
unmet need, get the total number of WRAs (15 - 49 years old)
% with with unmet need for modern family planning methods for the
at least 2 PPV month. For the annual proportion of FP unmet, copy the
December data and place this under the "Annual" Column.
b. Modern FP Unmet Among NHTS plus other non-NHTS poor

%Total
mCPRno. unmet need, get the total number of WRAs, 15-49 years old
of WRA with unmet need for modern (both NHTS household members plus non-NHTS poor)with
FP methods unmet need for modern family planning methods for the month.
For the annual proportion of FP unmet, copy the December
data and place this under the "Annual" Column.
c. Modern FP Unmet Need Among NHTS household members only
(IO 1.2.2.5.1)
unmet need, get the total number of WRAs, 15-49 years old
(NHTS household members only) with unmet need for modern
family planning methods for the month. For the annual
proportion of FP unmet, copy the December data and place
this under the "Annual" Column.
Proportion of WRA with

unmet need
Indicator 8. for modern FP a. NHTS plus other non-NHTS poor
8.1 Based on the updated TSEKAP Report, get the number of
those poor/indigents who are non-NHTS members given
Check-up for the month. Add this cumulatively on an annual
basis (Please do not include follow-up check ups and
returnees).
8.2 Get the total number of NHTS beneficiaries (members)
based on the listahan of DSWD and add the number of non-
NHTS poor members given check-up. Add this cumulatively on
(IO 1.2.1) an annual basis.
% of poor b. NHTS household members
provided with annual health 8.3 Based on the updated TSEKAP Report among NHTS
check-up members, get the total number of NHTS household members
who have undergone check-up for the month. Add this
cumulatively on an annual basis (Please do not include follow-
up check ups and returnees).
8.4 Get the total number of NHTS beneficiaries (members)
based on the listahan of DSWD.
Indicator 9. 9.1 Based on TB Registry/ITIS, get the total number of NEW

and RELAPSE TB cases on a monthly basis. Add
(IO 2.1) cumulatively on an annual basis.
Indicator 10. 10.1 Based on the Philippine Malaria Information System

(PhilMIS), get the total number of OLD and NEW malaria
cases on a monthly basis. Add cumulatively on an annual
basis.
Total no. of new and
relapse TB cases
Total no. of
confirmed malaria cases
Name of DMO : __________________________________
LGU Achievement DMO/RHSPMU Assessment
At the end of the year, PHTL/RHSPMU
assesses if LGU achieved the national program
target
1.2 At the end of the year, compute the % FIC by dividing the total number of fully National Program Target: 95%
immunized children (Item 1.1) by the estimated number of eligible population (2.7 %
of PSA projected population). Multiply this by 100.
Encircle the status

P - achieved
% FIC: ______________ X - not
achieved
2.2 At the end of the year, compute the % pregnant women with 4 or more prenatal National Program Target: 86%
visits by dividing the total number of pregnant women who had 4 or more prenatal
visits by the estimated number of pregnant women (2.7 % of PSA projected
population). Multiply this by 100.
Encircle the status
P - achieved
. X - not
achieved
3.2 At the end of the year, compute the % SBA deliveries by dividing the number of National Program Target: 99%
deliveries attended by SBAs (Item 3.1) by the total number of deliveries (Item B).
Multiply this by 100.
% with 4 or more prenatal visits: _____________
Encircle the status
.
P - achieved
X - not
achieved
4.2 At the end of the year, compute the % FBDs by dividing the% SBA: of deliveries National Program Target: 91%
number
_______________
in health facilities (Item 4.1) by the total number of deliveries (Item B). Multiply this
by 100.
.
Encircle the status
P - achieved
X - not
% FBD: _____________ achieved
5.2 At the end of the year, compute for % of women with at least 2 PP visits by National Program Target: 86%
dividing the total number of postpartum women with at least 2 postpartum visits by
the estimated number of postpartum women (2.7 % of PSA projected population).
Multiply this by 100.
Encircle the status
P - achieved
X - not
. achieved
6.2 At the end of the year, compute the % modern CPR by dividing the total number National Program Target: 52%
of all the current users of modern FP method (Item 6.1) by the estimated number of
WRA population (12.325 % of PSA projected population). Multiply this by 100.
% with
at least 2 PP visits: _______________
Encircle the status
. P - achieved
X - not
achieved
% mCPR: ______________
Name of DMO : ____________________

LGU Achievement DMO/RHSPMU Assessment
7.4 At the end of the year, compute the proportion of WRAs (15 - 49 years old) with National Program Target: < 5%
unmet need for modern FP method by dividing the total no. of WRAs (15-49 years
old) with unmet need for modern FP method (item 7.1) by the estimated number of
WRA population (12.325 % of PSA projected population). Multiply this by 100.
Encircle the status
P - achieved
X - not
achieved
7.5 At the end of the .year, compute the proportion of WRAs, 15-49 years old National Target: <5%
(NHTS household members plus non-NHTS poor) with unmet need for modern FP
method by dividing the total no. of WRAs (NHTS household members plus non-
NHTS poor)with unmet need for modern FP method (item 7.2) by the total number of
WRA, 15-49 years old (NHTS household members Proportion of WRApoor). Multiply
plus non-NHTS
this by 100. Encircle the status
/ - achieved
X - not
. achieved
with unmet need for modern FP: _____________
7.6 At the end of the year, compute the proportion of WRAs, 15-49 years old National Program Target: < 5%
(NHTS household members) with unmet need for modern FP method by dividing the
total no. of WRAs, 15-49 years old (NHTS household members) with unmet need
for modern FP method (item 7.3) by the total number of WRA, 15-49 years old
(NHTS household members). Multiply this by 100.
7.6 At the end of the year, compute the proportion of WRAs, 15-49 years old National Program Target: < 5%
(NHTS household members) with unmet need for modern FP method by dividing the
total no. of WRAs, 15-49 years old (NHTS household members) with unmet need
for modern FP method (item 7.3) by the total number of WRA, 15-49 years old
(NHTS household members). Multiply this by 100.
Encircle the status
P - achieved
X - not
. achieved
8.6 At the end of the year, compute the % of poor (NHTS plus non-NHTS poor) who National Target: 100 %
have received check-up by dividing the total number of NHTS household members
plus non-NHTS poor (Item 8.2) over the total number of NHTS beneficiaries (based
on the listahan of DSWD - Item 8.4) plus the total number of non-NHTS poor (item
b. Proportion of WRA, 15-49 years old (NHTS household
8.2). Multiply this by 100.
members).
Encircle the status

. with unmet need for modern / - achieved
FP : ________________ X - not
achieved
8.7 At the end of the year, compute the % of poor (NHTS household members) who National Target: 100 %
have received check-up by dividing total number of NHTS household member (Item
8.3) over the total number of NHTS beneficiaries (based on the listahan of DSWD -
Item 8.4). Multiply this by 100.
b. % of poor
(NHTS household members
Encircle the status
/ - achieved
. X - not
9.2 At the end of the year, compute the TB Incidence per 100,000 population by achieved
National Program Target: 225 per 100,000
dividing the total number of new and relapse TB cases (Item 9.1) by the total PSA
+ other
project population (Item A). Multiply this non-NHTS poor)
by 100,000.
.
Encircle the status
a. % of poor (NHTS
P - achieved
household members) provided
X - not
10.2 At the end of the year, compute the malaria prevalence per 100,000Tuberculosis achieved
population National Program Target: 0.05 per 100,000
by dividing the total number of old and new malaria cases (Item 10.1)provided
Incidence by the total
with
PSA
with projected
annual
annual population
checkcheck
up: (Item A). Multiply this by 100,000.
________________
up: ______________________
. Encircle the status
P - achieved
per 100,000 population: __________________ X - not
achieved
Malaria Prevalence
per 100,000: _____________

A. Indicator B. Operational Definition
Indicator 1. Proportion of infants who received 1 dose of BCG, 3 doses of OPV, 3 doses of Pentavalent vaccine and 2 doses of
measles containing vaccines at 12 months old
Indicator 2. Proportion of pregnant women visited/ seen by the midwife/ nurse/ doctor at home or at a health facility at least once
during the first and second trimesters and twice during the third trimester during a given period
Indicator 3. Proportion of deliveries attended by skilled health professional who are licensed health professionals such as
midwife, doctor or nurse, during a given period. Skilled health professional has been trained to proficiency to manage
pregnancies, childbirth and the immediate postnatal period and identification, management and/or referral of
complications in women and newborns.
% FIC
Indicator 4. % with at Proportion of deliveries delivered in a health facility such as hospitals, lying-ins, rural health units, barangay health
least 4 ANC stations, private clinics and the like during a given period.
(IO 1.1.4.1)
(IO 1.2.2.4.1)
% SBA
Indicator 5. Proportion of deliveries that received post-partum visits by a midwife/nurse/doctor at home or at a health facility at
least twice after delivery such that the first visit is within 24 hours upon delivery and the second visit within one week
after delivery during a given period.
Indicator 6. Proportion of women aged 15-49 years old who are currently using (or whose partner is using) any modern method
of contraception or family planning, which includes: the pill, female and male sterilization, IUD, injectables, implants,
condom, and natural FP methods such as cervical mucus, basal body temperature, symptothermal method, standard
days method and lactation amenorrhea method during a given period
% with
at least 2 PPV
(IO 1.2.2.5.1)
% using mCPR
(IO 1.2.2.1.1)
Indicator 7. a. Modern FP Unmet Need Among Generral Population

Proportion of women (aged 15-49 years old) who are fertile and sexually active but:
1.want to limit number of children but not using any modern method; or
2.want to space/delay the birth of the next child but not using any modern method; or
3.using traditional method during a given period
b. Modern FP Unmet Among NHTS plus other non-NHTS poor

Proportion of WRA (aged 15-49 Proportion of NHTS and other non-NHTS poor women (aged 15-49 years old) who are fertile and sexually active but:
years old) with unmet need for modern family 1.want to limit number of children but not using any modern method; or
planning 2.want to space/delay the birth of the next child but not using any modern method; or
c. Modern FP Unmet Need Among NHTS household members only

Proportion of NHTS poor women (aged 15-49 years old) who are fertile and sexually active but:
1.want to limit number of children but not using any modern method; or
(IO 1.2.1)
2.want to space/delay the birth of the next child but not using any modern method; or
Indicator 8. a. NHTS plus other non-NHTS poor

Proportion of NHTS households members and non-NHTS poor that were provided with an annual health check-up in
public health facilities (BHS/HC, RHU/MHC, LGU and national-owned hospitals) and through other schemes
facilitated by the public health workers such as home visits, outreach program to GIDA during a given period. The
poor that will be included in the counting were those provided with at least 3 services, with at least 1 of the 3 services
provided by a doctor. This shall exclude follow-up check-ups, and check-ups conducted by other organizations.
b. NHTS household members

b. Proportion of NHTS households members that were provided with an annual health check-up in public health
facilities (BHS/HC, RHU/MHC, LGU and national-owned hospitals) and through other schemes facilitated by the
public health workers such as home visits, outreach program to GIDA during a given period The poor that will be
included in the counting were those provided with at least 3 services, with at least 1 of the 3 services provided by a
doctor. This shall exclude follow-up check-ups, and check-ups conducted by other organizations.
% of poor provided with annual health check-

up (PHA)
Indicator 9. Estimated number of new and relapse TB cases (all forms of TB) arising in a given year, expressed as a rate per
100,000 population
Indicator 10. Total number of malaria cases during a given period, expressed as a rate per 100,000 total population
Tuberculosis incidence rate per 100,000

population
Malaria Prevalence per 100,00 population
(FO 1.6.3)
(FO
1.6.4)
C. Formula
Numerator: Total number of children who received 1 dose of BCG, 3 doses of OPV, 3 doses of Pentavalent
vaccine and 2 doses of measles containing vaccines before reaching 12 months old during a given period
Denominator: Total number of estimated eligible population

(2.7% of PSA projected population)
Numerator: Total number of pregnant women with 4 or more prenatal visits during a given period
Multiplier: 100
Denominator: Total number of estimated pregnant women (2.7% of PSA projected population)
Multiplier: 100
Numerator: Total number of deliveries attended by a skilled health professional during a given period
Denominator: Total number of deliveries
Multiplier: 100
Numerator: Total number of deliveries in a health facility during a given period
Multiplier: 100
Numerator: Total number of deliveries with at least 2 PP visits 4 or more prenatal visits during a given period
Multiplier: 100
Numerator: Total number of WRA who are current users of modern FP method during a given period
Denominator: Total number of estimated WRA population (12.325% of PSA projected population)
Multiplier: 100
C. Formula
Numerator: Total number of women of reproductive age (15 - 49 years old) with unmet need for modern family planning methods
during a given period
Denominator: Total number of estimated WRA population (12.325% of PSA projected population)
Multiplier: 100
Numerator: Total number of women of reproductive age, 15-49 years old (both NHTS household members plus non-NHTS poor) with
unmet need for modern family planning method during a given period
Denominator: Total number of WRA, 15-49 years old (both NHTS household members plus non-NHTS poor)
Multiplier:
100
Numerator: Total number of women of reproductive age, 15-49 years old (NHTS household members only) with unmet need for
modern family planning method during a given period
Denominator: Total number of WRA, 15-49 years old (NHTS household members only)
Multiplier:
100
Numerator: Number of NHTS household members and non-NHTS poor provided with annual health check-up during a given period
Denominator: Total number of NHTS household members based on the listahanan of DSWD and non-NHTS poor during a given
period
Multiplier: 100
Numerator: Number of NHTS households members provided with annual health check-up during a given period
Denominator: Total number of NHTS household members based on the listahanan of DSWD during a given period
Multiplier: 100
Numerator: Total number of new and relapse TB cases arising in a specific period cases during a given period
.
Denominator: Total PSA projected population during a given period

.
Numerator: Total number of malaria cases during a given period
.
Multiplier:
100,000

.
Multiplier:
100,000
Module 1 - Data Collection Form at the RHU/MHC
Module 1.b QUARTERLY Health Sector Performance Monitoring and Evaluation
For the Period: __________________________
Name of PHA : ________________________________________ Name of Municipality/City : ___________________________________________
Performance Instructions/Guide
Indicator Quarter: _________________ Quarter: _________________ Quarter: _________________ Quarter: ________________
Indicator 11. 11.1 Based on the FHSIS Report,
get the total number of leprosy
cases on a quarterly basis. Add
Indicator 12. 12.1 List the name of your Verify if your RHU/MHC has a functional EMR systems Verify if your RHU/MHC has a functional EMR systems Verify if your RHU/MHC has a functional EMR systems Verify if your RHU/MHC has a functional EMR syste
RHU/MHC on the space
provided
P - if EMR is functional X - if EMR is not P - if EMR is functional X - if EMR is not P - if EMR is functional X - if EMR is not P - if EMR is functional X - if EM
functional functional functional funct
Total:
Total no. of leprosy

cases
Indicator 13. 13.1 List the name of all presence of determine the category of Status presence of determine the category of Status presence of determine the category of Status presence of determine the category of
barangays in your public health the personnel public health the personnel public health the personnel public health the personnel
municipality/city and check the worker worker worker worker
succeeding columns
accordingly.
(X) (P) MD RN RM (X) (P) MD RN RM (X) (P) MD RN RM (X) (P) MD RN RM
1 yes yes yes yes

P - if P - if P - if P - if
none fully dedicated none fully dedicated none fully dedicated none fully dedicated
2
10
Total
% of barangays
with at least one
dedicated public
health worker
(midwife, nurse,
doctor)
(OP 3)
Name of DMO : ____________________
_______ Annual
11.2 At the end of the year, compute the leprosy prevalence by
dividing the total number of leprosy cases (Item 11.1) by the total
PSA projected population (Item A). Multiply this by 10,000.
EMR systems 12.2 For the annual, copy the 4th quarter status.
Leprosy Prevalence Rate: __________
X - if EMR is not P - if EMR is functional X - if EMR is not
functional functional
Status 13.2 For the annual, copy the 4th quarter status.
presence of determine the category of Status
public health the personnel
worker
(X) (P) MD RN RM
yes
none P - if
use additional sheet as needed
Indicator 11. Prevalence is the number of leprosy cases registered at a given point in time and the prevalence rate is per 10,000 total population.
A case of leprosy is a person presenting clinical signs of leprosy (with or without bacteriological
examination) who has yet to complete a full course of treatment. A patient who has completed a full course of fixed duration MDT (6 doses for PB and 12
doses for MB) is cured. An MB patient who has not collected treatment for
6 consecutive months and a PB patient who has not collected treatment for 3 consecutive months are considered defaulter and should start retreatment
but not removed from the prevalence.
Includes
Indicator 12. Percentage of public health facilities such as LGU and DOH hospitals, rural health units, urban health centers, health centers and other
health facilities that uses iClinicSys, HOMIS or any other EMR systems. Functionality means that the EMR system can generate timely
report as required by the management
% of health facilities with functional

Leprosy EMR
Prevalence
systems
Rate
Indicator 13. Proportion of barangays with at least one dedicated public health worker (doctor, nurse, or midwife). This shall include permanent
personnel, job orders/ contractual, and DOH deployed. If the HRH has been assigned to several barangays, he/she shall choose one
(PR 1) barangay which will be counted as his/her base assignment. This shall be the one reflected in the monitoring tool. Barangays with rotating
health workers only shall not be included in the counting.
(FO 1.6.2)
% of barangays with at least

one dedicated public health worker
(OP 3)
C. Formula
Numerator: Total number of leprosy cases during a given period

.

.
Numerator: Number of public health facilities 10,000

Multiplier: with functional EMR systems during a given period
Denominator: Total number of public health facilities during a given period
Multiplier: 100
Numerator: Number of barangays with at least one dedicated public health worker during a given period
.
Denominator: Total number of barangays during a given period
Multiplier: 100
Module 1. Data Collection Form at the RHU/MHC
Module 1.c ANNUAL Health Sector Performance Monitoring and Evaluation
For the Period: __________________________
Name of PHA : ________________________________________ Name of Municipality/City : ____________________________________
Performance Indicator Instructions/Guide DMO/RHSPMU Assessment Performance Indicator
LGU
Achievement
Item A. Get the total PSA projected population of your LGU. At the end of the year, Indicator 18.
PHTL/RHSPMU assesses if
LGU achieved the national
program target
Indicator 14. 14.1 Based on the OPT Report (First Round of theYear), get the total number of National Program Target:
overweight children under 5 years of age (0 - 59 months). < 3.9%
14.2 Indicate the total number of children whose weights and heights were measured Indicator 19.
during the OPT.
Total Projected Population Encircle the status
14.3 Compute the proportion of overweight children under 5 years old by dividing the
total number of overweight children (Item 14.1) by the total number of children whose P-
weights and heights were measured during the OPT - Item 14.2). Multiply this by 100. achieved
X - not achieved Proportion of

Indicator 15. 15.1 Based on the OPT Report (First Round of the Year), get the total number of National Program Target: households with
wasted children under 5 years of age (0 - 59 months). < 5% access to improved or
safe water20.
Indicator supply
15.2 Indicate the total number of children whose weights and heights were measured
during the OPT. Encircle the status
15.3 Compute the proportion of wasting among children under 5 years old by dividing
the total number of wasted children (Item 15.1) by the total number of children whose P-
weights and heights were measured during the OPT - Item 15.2). Multiply this by 100. achieved Proportion of
households using
X - not achieved safely managed
Indicator drinking
Indicatorwater
21. services
Proportion16.
of 16.1 Based on the OPT Report (First Round of the Year), get the total number of
stunted children under 5 years of age (0 - 59 months).
National Program Target:
overweight children 21.4%
under 5 years of age (IO 1.5.1)
16.2 Indicate the total number of children under 5 years oldwhose heights were
measured during the OPT. Encircle the status
16.3 Compute the proportion of stunting among children under 5 years old by dividing P-
the total number of stunted children (Item 16.1) by the total number of children under achieved
5 years old whose heights were measured during the OPT - Item 16.2). Multiply this Indicator 22.
by 100.
X - not achieved
Indicator 17. 17.1 Specify if PHO/CHO/MHO has institutionalized DRRM - H
P - if with institutionalized DRRM - H % of barangays

with "Zero Open
Proportion of Defecation" status
stunted children under X - if no institutionalized DRRM - H
5 years of age
% of Local Government
Health Facilities (LGHFs)
with institutionalized %
Disaster Risk Reduction of municipalities/cities
Management for Health
with 1 RHU/MHC to
(DRRM-H) system
20,000 population
(IO 1.5.3)
(IO
1.1.3)
(IO 2.4)
(OP 5)
dule 1. Data Collection Form at the RHU/MHC
h Sector Performance Monitoring and Evaluation
r the Period: __________________________
Name of DMO : _______________________________
Instructions/Guide DMO/RHSPMU
LGU
Assessment
Achievement
18.1 Get the total number of households with access to improved or safe water supply. National Program
Target: 95%
18.2 Indicate the number of households in your municipality/city. Encircle the status
18.3 Compute the proportion of households with access to improved or safe water supply P - achieved
by dividing the number of households with access to improved or safe water supply (Item
19.1) by the total number of households (Item 19.2). Multiply this by 100.
X - not
achieved
19.1 Get the total number of households with access to improved water sources located in
the premises and free from E.coli
19.2 Indicate the no. of households in your municipality/city.
19.3 Compute the proportion of households with access to improved water sources
located in premises and free from E.coli by dividing the number of households with
access to improved water sources located in premises and free from E.coli (Item 19.1) by
the total number of households (Item 19.2). Multiply this by 100.
20.1 Get the total number of households using safely managed sanitation services. National Program
Target: 95%
20.2 Indicate the number of households in your municipality/city. Encircle the status
20.3 Compute the % of households using safely managed sanitation services by dividing
the number of households using safely managed sanitation services (Item 20.1) by the P - achieved
total number of households (Item 20.2). Multiply this by 100.
X - not
achieved
21.1 Indicate the total barangays declared with zero open defecation status. National Program
Target: 100%
21.2 Indicate the total number of barangays in your municipality/city .
21.3 Compute the % of barangay with zero open defecation status by dividing the number P - achieved
of barangay with zero open defecation status (Item 21.1) by the total number of barangays
in your municipality/city (Item 21.2). Multiply this by 100.
X - not
achieved
22.1 Indicate the total number of existing RHUs/MHCs in your municipality/city.
22.2 Compute the desired number of RHU/MHC in the LGU by dividing the total population
by 20,000.
22.3 Check if the number of existing RHUs/MHCs (Item 22.1) is equal or higher than the
desired number of RHUs/MHCs needed for the given PSA projected population of your
municipality/city.
(a) Encircle (/) if existing no. of RHU/MHC is equal or
higher than the desired number of RHU/MHC.
(b) Encircle (X) if the existing number of RHU/MHC is lower than the desired number
of RHU/MHC.
Indicator 14. Percentage of children aged 0-59 months old whose weight for height are >+2 standard deviation from the median weight for height of the WHO Child Growth Standards. This shall include mild, moderate
and severe cases.
Indicator 15. Percentage of children aged 0-59 months old whose weight for height are less than 2 standard deviation from the median weight for height of the WHO Child Growth Standards. This shall include mild,
moderate and severe cases.
Indicator 16. Percentage of children aged 0-59 months old whose height for age are less than 2 standard deviation from the median height for age of the WHO Child Growth. This shall include mild, moderate and severe
cases.
Proportion of
overweight children under 5 years of
Indicator
age 17. Percentage of the actual number of targeted LGHFs having institutionalized DRRM-H system.
LGHFs Provincial/ City/ Municipal Health Offices, LGU-owned hospitals/facilities (provincial and district hospitals)
Institutionalized DRRM-H System is the availability of ALL of the following:
1. DRRM-H Plan
2. Trained and equipped health emergency managers and responders
Proportion of stunted children under 5 3. Commodities
years of wasted children under 5 4. Operation center
of age
Proportion
years of age
Indicator (IO
18. 1.1.1) Refers to households covered by or have access to the following improved types of drinking water sources
% of Local Government Health Definition of terms:
Facilities (LGHFs) with institutionalized Level I (Point Source) refers to a protected well (shallow and deep well), improved dug well, developed spring, or rainwater cistern with an outlet but without a distribution system, generally adaptable for
Disaster Risk Reduction Management rural areas where the
for Health (DRRM-H) system houses are thinly scattered. A level I facility normally serves around 15 households.
(IO Level II (Communal Faucet System or Standposts) refers to households covered by or have access to the
1.1.3) following improved types of drinking water sources
(IO 1.1.2) Definition of terms: Level I (Point Source) refers to a protected well (shallow and deep well), improved dug well, developed spring, or rainwater cistern with an outlet but without a distribution system,
generally adaptable for rural areas where the houses are thinly scattered. A level I facility normally serves around 15 households.
Proportion of households with access Level II (Communal Faucet System or Standposts) refers to a system composed of a source, a reservoir, a piped distribution network, and a communal faucet located not more than 25 meters from the
to improved or safe water supply farthest house. It is generally suitable for rural and urban areas where houses are clustered densely enough to justify a simple piped water system. Usually, one faucet serves 4 6 households. Note: For
reporting purposes Level II system may also include a communal faucet connected to Level III where group of households get their water supply.
(IO 2.4) Level III (Waterworks System) a system with a source, transmission pipes, a reservoir, and a piped distribution network for household taps. It is generally suited for densely populated areas. Examples of
these are MWSSand water districts with individual household connections.
(IO 1.5.1)
Indicator 19. Refers to households using an improved drinking water source which is:
-located on premises,
-available when needed, and
-free of fecal and priority chemical contamination
Located in premises - when the water is either piped into household dwelling or yard/plot or a point source located within the household premises
Free of fecal contamination water is free from E. coli.
Water supply found with E.coli should be corrected and conduct resampling.
Indicator 20. Proportion of households using a basic sanitation facility at the household level (flush or pour-flush toilets to sewer systems, septic tanks or pit latrines, ventilated improved pit latrines, pit latrines with a slab,
Proportion of households using safely and composting toilets) which is not shared with other households and where excreta are safely disposed in situ or treated off-site during a given period
managed drinking water services
Indicator 21. Proportion of barangays declared with Zero Open Defecation (ZOD) status during a given period following DOH guidelines.
Zero open defecation is defined as no feces openly visible or exposed to the environment. Achieving ZOD might involve the use of any form of toilets that prevent exposure of feces to the environment with
provision for moving up the sanitation ladder. (DM2015-0021)
(IO 1.5.1.1)
Proportion of households using safely
Indicator 22. Total number of municipalities and cities which meet the desired 1 RHU/MHC to 20,000 population ratio among all municipalities and cities nationwide during a given period
managed sanitation services
% of
barangays with "Zero Open
Defecation" status
(IO 1.5.2)
% of municipalities/cities with 1
RHU/MHC to 20,000 population
(IO 1.5.3)
(OP 5)
C. Formula
Numerator: Total number of overweight children aged 0-59 months old
Denominator: Total number of children whose weights and heights were measured
Multiplier: 100
Numerator: Total number of wasted children aged 0-59 months old

Denominator: Total number of children whose weights and heights were measured
Multiplier: 100
Numerator: Total number of stunted children aged 0-59 months old

Denominator: Total number of children heights were measured
Multiplier: 100
Numerator: Number of LGHFs [Provincial/ City/ Municipal Health Offices, LGU-owned

hospitals/facilities (provincial and district hospitals)]
with institutionalized DRRM-H system during a given period
Denominator: Total number of LGHFs [Provincial/ City/ Municipal Health Offices, LGU-
owned hospitals/facilities (provincial and district hospitals)] during a given period
Multiplier: 100
Numerator: Number of households using safely managed drinking water services during a
given period
Denominator: Total number of households during a given period
Multiplier: 100
.
Note: For reporting purposes Level III system may also include a Level I system with piped
distribution for household tap serving group of housing dwellings such as apartments or
condominiums
Numerator : Number of households with access to improved water sources located in the
premises and free of E.coli during a given period
Denominator : Total number of households during a given period
Multiplier: 100
Numerator: Number of households using safely managed sanitation services during a given
period
Multiplier: 100
Numerator: Number of barangays declared with ZOD status during a given period
Multiplier: 100
Numerator: Number of municipalities and cities which has at least 1 RHU/MHC to 20,000
population during a given period
Denominator:Total number of municipalities and cities nationwide during a given period
Multiplier: 100
Module 2. Data Collection Form at the Local Civil Registry
For the Period: __________________________
Name of PHA : ________________________________________ Name of Municipality/City : _________________________________________________ Name of DMO : _______________________________
Performance Indicator Instructions/Guide Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Annual LGU Achievement PHTL/RHSPMU Assessment
NOTE: Before filling-up this section, ensure to accomplish first Module 2.a.1 List of Registered Under-Five Deaths and Module 2.a.2 List of Registered At the end of the year,
Maternal Deaths. DMO/RHSPMU assesses if
LGU achieved the national
Item A. Get the total PSA projected population of your LGU. program target
Item C. Get total number of live births from the Local Civil Registry
for the month. Add this cumulatively on an annual basis.
Indicator 23. 23.1 Based on the accomplished Module 2.a.1 List of 23.2 At the end of the year, compute the NMR by dividing the National Program Target:
Registered Under-Five Deaths, get from column A the total no. of neonatal deaths (Item 23.1) by the total no. of live births
no. of neonatal deaths registered for the month. Add this (Item C). Multiply this by 1,000.
P - achieved
Total X - not
Indicator
Projected24.
Population 24.1 Based on the accomplished Module 2.a.1 List of 24.2 At the end of the year, compute the IMR by dividing the National Program Target:
achieved
Registered Under-Five Deaths, get from column D the total no. of infant deaths (Item 24.1) by the total no. of live births
no. of infant deaths registered for the month. Add this (Item C). Multiply this by 1,000 Neonatal
cumulatively on an annual basis. Mortality Rate: __________________ 10/1,000LB
Encircle the status
.
P - achieved
X - not
Indicator 25. 25.1 Based on the accomplished Module 2.a.1 List of 25.2 At the end of the year compute the UFMR by dividing National Program Target:
achieved
Neonatal
Registered Under-Five Deaths, get from column E the total the no. of under-five deaths (Item 25.1) by the total no. of live
Mortality Rate
no. of under-five deaths registered for the month. Add this births (Item C). Multiply this by 1,000. Infant
cumulatively on an annual basis. Mortality Rate: __________________
Encircle the status
. 15/1,000LB
Total P - achieved
Number of Live Births X - not
Indicator 26. 26.1 Based on the accomplished Module 2.a.2 List of 26.2 At the end of the year, compute the MMR by dividing the National Program Target:
achieved
Registered Maternal Deaths, get the total no. of maternal no. of maternal deaths (Item 26.1) by the total no. of live births
Infant Mortality Rate deaths registered for the month. Add this cumulatively on an (Item C). Multiply this by 100,000. Under-
annual basis. Five Mortality Rate: __________________
Encircle the status
. 22/1,000LB
P - achieved
Under-Five Mortality X - not
achieved
Rate
(FO 1.2.3)
Module 2. Data Collection Form at the Local Civil Registry
For the Period: __________________________
Name of PHA : ________________________________________ Name of Municipality/City : _________________________________________________ Name of DMO : _______________________________
Performance Indicator Instructions/Guide Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Annual LGU Achievement PHTL/RHSPMU Assessment
Indicator 27. 27.1 Get from the Local Civil Registry Office the number of 27.2 At the end of the year, compute for the Premature Mortality Rate due National Program Target:
deaths (30 to 70 years old) due to CVD, Cancer (all sites), to NCDs by dividing the number of deaths due to CVD, Cancer (all sites),
DM II and Chronic Respiratory Diseases (Item 27.1) by the total PSA
DM II and Chronic Respiratory Diseases (CRD) registered projected population (Item A). Multiply this by 100,000.
for r the month. Add this cumulatively on an annual basis.
P - achieved
X - not
achieved
<122/100,000
Indicator 28. 28.1 Get from the Local Civil Registry Office the number of 28.2 At the end of the year, compute the Premature Mortality Rate due to
Premature
CVD by dividing the number of deaths due to CVD (Item 28.1) by the total
deaths (30 to 70 years old) due to CVD registered for the
Mortality Rate
PSA projected population (Item A). Multiply this by 100,000.
month. Add this cumulatively on an annual basis.
deaths (30 to 70 years old) due to DM II registered for the Premature
DM II by dividing the number of deaths due to DM II (Item 29.1) by the
month. Add this cumulatively on an annual basis. Mortality Rate population (Item A). Multiply this by 100,000.
total PSA projected
due to NCDs per 100,000:

.
__________________
Premature Mortality
Rate due to NCDs per
Indicator
100,000 30. 30.1 Get from the Local Civil Registry Office the number of 30.2 At the end of the year, compute the Premature Mortality Rate due to
deaths (30 to 70 years old) due to Chronic Respiratory Chronic Respiratory Diseases by dividing the number of deaths due to
Premature Mortality
Chronic Respiratory Rate (Item 30.1) by the total PSA projected
Diseases
Diseases registered for the month. Add this cumulatively on population (Item A). Multiply this by 100,000.
Premature Mortality an annual basis.
Rate due to CVD due to CVD per 100,000:
.
__________________
Premature
Cancer, all sites by dividing the number of deaths Mortality
due to Cancer, all sites
Premature deaths (30 to 70 years old) due to Cancer, all sites
Rate
(Item 31.1) by the PSA total projected population (Item A). Multiply this by
Mortality Rate due to registered for the month. Add this cumulatively on an annual 100,000. due to DM II per 100,000:
DM II basis. __________________
(FO .
1.4.1)
Premature Mortality
Indicator
Rate due 32.
to Chronic 32.1 Get from the Local Civil Registry Office the number of 32.2 At the end of the year, compute the Mortality Rate due to Road National Program Target:
Premature
Traffic Injuries Mortality
by dividing Rateof deaths due to road traffic injuries
the number
Respiratory Diseases deaths due to road injuries registered for the month. Add
(Item 32.1) by the PSAtotal projected population (Item A). Multiply this by
this cumulatively on an annual basis. 100,000. due to CRD per 100,000: __________________
(FO 1.4.1.1)
.
deaths due to road injuries registered for the month. Add Traffic Injuries by dividing the number of deaths due to road traffic injuries
(Item 32.1) by the PSAtotal projected population (Item A). Multiply this by
this cumulatively on an annual basis. 100,000.
P - achieved
X - not
achieved
Death Rate
Death Rate due to

Road Traffic Injuries
due to Road Traffic Injuries:
__________________
(FO 1.6.1)
Indicator 23. The number of deaths among neonates (deaths within first 28 days of life), expressed as a rate per 1,000 live births
Neonatal Mortality Rate

Indicator 24. The number of deaths among infants (below one year of age), expressed as a rate per 1,000 live births
(FO
1.2.3)
Indicator 25. Infant Mortality Rate The number of deaths among children under five years old, expressed as a rate per 1,000 live births
Under-Five Mortality Rate

Indicator 26. The number of maternal (pregnancy, childbirth and puerperium-related) deaths (as confirmed by the MHO/CHO) expressed as a ratio per
100,000 live births.
Maternal Mortality Ratio

Indicator 27. The number of deaths among 30 to 70 years old Filipinos attributed to cardiovascular diseases, cancer, diabetes mellitus II and chronic
respiratory diseases, expressed as a rate per 100,000 total population. This shall cover deaths with ICD codes of: I00 I99; C00 C97;
E10 E14; and J40 J47.
Indicator 28. The number of deaths among 30 to 70 years old Filipinos attributed to cardiovascular diseases, expressed as a rate per 100,000 total
Premature Mortality Rate due to NCDs per population. This shall cover deaths with ICD codes of: I00 I99.
100,000
IndicatorPremature
29. Mortality Rate due to
CVD(FO 1.4.1) The number of deaths among 30 to 70 years old Filipinos attributed to diabetes mellitus II, expressed as a rate per 100,000 total
population. This shall cover deaths with ICD codes of: E10 E14.
(FO 1.4.1.1)
Premature Mortality Rate due to DM II
Indicator 30. The number of deaths among 30 to 70 years old Filipinos attributed to chronic respiratory diseases, expressed as a rate per 100,000
total population. This shall cover deaths with ICD codes of: J40 J47.
Premature Mortality Rate due to

(FO 1.4.1.3)
Chronic Respiratory Diseases
Indicator 31. The number of deaths among 30 to 70 years old Filipinos attributed to cancer diseases, expressed as a rate per 100,000 total population.
This shall cover deaths with ICD codes of: C00 C97.
Indicator 32. Premature Mortality

Rate due to Cancer, all sites
The number of deaths due to road injuries, expressed as a rate per 100,000 population. This shall cover deaths with ICD codes of: V01
V89.
Death Rate due to Road Traffic

Injuries (FO 1.4.1.2)
(FO 1.6.1)
C. Formula
Numerator:
Number of deaths of neonates within the first 28 days of life during a given period
Denominator:
Total number of livebirths during a given period
Multiplier: 1,000
Numerator:
Number of infant deaths under 1 year old during a given period
Denominator:
Multiplier: 1,000
Numerator:
Number of deaths below age 5 during a given period
Denominator:
Multiplier: 1,000
Numerator:
Number of maternal deaths during a given period
Denominator:
Multiplier: 100,000
C. Formula
Numerator:
Number of deaths among 30 to 70 years old attributed to cardiovascular
diseases, cancer, diabetes mellitus II and chronic respiratory diseases during a
given period
Denominator:
Total PSA projected population during a given period
Multiplier: 100,000
Numerator:
Number of deaths among 30 to 70 years old attributed to cardiovascular diseases
Denominator:
Total number of estimated population during a given period
Multiplier: 100,000
Numerator:
Number of deaths among 30 to 70 years old attributed to diabetes mellitus II
Denominator:
Multiplier: 100,000
Numerator:
Number of deaths among 30 to 70 years old attributed to chronic respiratory
diseases during a given period
Denominator:
Multiplier: 100,000
Numerator:
Number of deaths among 30 to 70 years old attributed to cancer during a given
period
Denominator:
Multiplier: 100,000
Numerator:
Number of deaths due to road injuries during a given period
Denominator:
Multiplier: 100,000
Module 2.a.1 List of Reported Under Five Deaths
Health Sector Performance Monitoring and Evaluation
Name of Municipality/City : ________________________________________________
Name of PHA : ______________________________ Name of DMO : __
Instruction:
1. Go to the Local Civil Registry Office and get the names of underfive deaths registered for the month. Write these below the "CRVS" under Column 1
within the month.
2. Specify the age of underfive deaths by checking the appropriate column (Columns A, B, C).
3. Indicate the sex of the underfive deaths by checking the appropriate column for sex.
4. Go to the "RHU/MHC" and validate if there are other underfive deaths reported outside the CRVS List. Add these names below the RHU/MHC in Co
5. Check the appropriate age group (Column A, B or C ) and specify sex of the underfive death/s
6. Go to the nearby hospitals and validate if there are other underfive deaths reported outside the CRVS and RHU/MHC Lists. Add these below the " H
7. Check the appropriate age group (Column A, B or C ) and specify sex of the underfive death/s
For the Month of ______________________ (A) (B) (C) (D)
0-28 days 1-11 months 12-59 months

Child
CRVS
1
Get the total
2 no. of Infant Deaths by adding
Neonate Deaths (Column A) and
3 Infant Deaths (Column B)
RHU/MHC
1
3
Neonate Infant
Hospitals
1
10. Add all neonatal, infant, child and underfive deaths reported for the
month. Sub total:

Child
CRVS
1
Get the total
RHU/MHC
1
3
Neonate Infant
Hospitals
1
month. Sub total:

Child
CRVS
1
Get the total
RHU/MHC
1
3
Neonate Infant
Hospitals
1
month. Sub total:
Total for the Quarter
Total for the Year

____
ame of DMO : _______________________________
" under Column 1. Ensure that the date of death is
e RHU/MHC in Column 1.
ese below the " Hospitals" in Column1.
(E) Sex
M F
Get the total no. of Under-

Five Deaths by adding Neonate Deaths
(Column A), Infant Deaths (Column B),
and Child Deaths [Column C].
(E) Sex
M F

(E) Sex
M F

Module 2.a.2 List of Confirmed Maternal Deaths
Name of Municipality/City : ________________________________________________
Name of PHA : ______________________________
Instruction:
1. Go to the Local Civil Registry Office and get the names of the reported maternal deaths on a monthly basis. Write these on the space provided for th
CRVS under the First Column.
2. Go to the RHU/MHC and validate if there are other maternal deaths reported (confirmed by the PHO/CHO) outside the CRVS List. Write these o
space provided for the RHU/MHC.
3. Go to the nearby hospitals and validate if there are other maternal deaths reported outside the CRVS and RHU/MHC List. Write these on the space
provided for the Hospitals.
For the Month of:
CRVS
1
RHU/MHC
1
Hospitals
1
4. Add all maternal deaths reported for the month. Sub total:
For the Month of:

CRVS
1
RHU/MHC
1
Hospitals
1
For the Month of:

CRVS
1
RHU/MHC
1
3
other Hospitals
1
Total for the Quarter
Total for the Year

List of Confirmed Maternal Deaths
erformance Monitoring and Evaluation
_____________________________________________
Name of DMO : _______________________________
reported maternal deaths on a monthly basis. Write these on the space provided for the
eaths reported (confirmed by the PHO/CHO) outside the CRVS List. Write these on the
rnal deaths reported outside the CRVS and RHU/MHC List. Write these on the space
al:
al:
al:
Module 3. Data Collection Form at the Government Hospitals (Community, District, Provincial, and DOH-Retained Hospital)
For the Period: __________________________
Name of PHA : _______________________________ Name of Municipality/City: ________________________
Name of Hospital Indicator 33. Indicator 34. Indicator 35. Indicator 36.
population ratio
Caesarean Delivery Rate

% of
1.List the names of all public hospital/s in your 33.1 Get the total number of caesarean deliveries for the % of health facilities government hospitals with Quality
34.1 Verify if your hospital is with functional EMR 35.1 Verify if your provincial and DOH-Retained 36.1 Specify the functional capacity of e
municipality/city quarter. Add this cumulatively on an annual basis. with functional
system Management
hospital is ISOSystem
certified(QMS) hospital
33.2 Get the total number of caesarean deliveries for the year.
(IO 2.2)
No. of Caesarean Deliveries
Q1 Q2 Q3 Q4 Annual Q1 Q2 Q3 is functional
P - if EMR Q4 Q1 P - if Q2
provincial andQ3 DOH-Retained
Q4 Infirmary (P)level 1 level 2
appropriately
EMR (Electronic hospital hospital is ISO certified
Infirmary 1 Medical Records) Systems
(PR 4)
Infirmary 2 QUARTERLY
X - if EMR is not functional X - if provincial and

DOH-Retained hospital hospital is NOT ISO
certified
(PR 1) QUARTERLY
Community Hospital
District Hospital
Provincial Hospital
QUARTERLY
DOH-Retained Hospital
Total
Name of DMO : ____________________________
Hospital bed to
(OP 4)
pacity of each 36.2 Indicate the total number of beds of each
hospital both authorized and implemented
ANNUAL
level 3 Authorized Implemented
use additional sheet as needed
Indicator 33. Proportion of deliveries via cesarean section (C-section) in a specific geographical area and reference period
Indicator 34. Percentage of public health facilities such as LGU and DOH hospitals, rural health units, urban health centers, health centers and other
health facilities that uses iClinicSys, HOMIS or any other EMR systems. Functionality means that the EMR system can generate timely
report as required by the management
Indicator%35.
of health facilities with Percentage of government owned hospitals (DOH and provincial hospitals) with ISO certification
% of government hospitals
with Quality Management System (QMS)
Indicator 36. The ratio of the total government hospital beds (covering all categories of hospitals) vis--vis the total population. HSPMU will collect
authorized and implementing bed capacity of Level 1, 2, and 3 government hospitals, and infirmaries.
C. Formula
Numerator: Number of deliveries via cesarean section during a given period
Denominator: Total number of deliveries during a given period
Multiplier: 100
Numerator:
Number of public health facilities with functional EMR systems during a given
period
Denominator:
Total number of public health facilities during a given period
Multiplier: 100
Numerator:
Number of government hospitals (DOH and provincial hospitals) with ISO
certification during a given period
Denominator:
Total number of government hospitals (DOH and provincial hospitals) during a
given period
Multiplier: 100
Numerator: Total estimated population
Denominator: Total number of beds from all hospitals in various categories within
the LGU
(HSPMU will collect Authorized bed capacity of Level 1,2, and 3 government
hospitals, and infirmaries)
Module 4. Data Collection Form at the Provincial Level
Module 4.b QUARTERLY Health Sector Performance Monitoring and Evaluation
For the Period: __________________________
Name of DMO : ________________________________________ Name of Municipality/City : ____________________________
Performance Indicator Instructions/Guide
Quarter : ____________________ Quarter : ____________________ Quarter : ____________________
Indicator 37. % of 37.1 Indicate the name of your municipality/city: MCP NCP TB-DOTS PCB 1 Accreditation MCP NCP TB-DOTS PCB 1 Accreditation MCP NCP TB-DOTS PCB 1
municipalities/cities with at least status status
one public health facility
accredited by PhilHealth for 37.2 Indicate the name of your RHU/MHC and check the status if: (P) - LGU (P) - LGU
with HFs with HFs
maternity care, newborn care RHU/MHC1 accredited accredited
package, TB-DOTS, and PCB 1 for 4 for 4
packages. PhilHealth PhilHealth
RHU/MHC2 Packages Packages
(OP RHU/MHC3
1)
RHU/MHC4
RHU/MHC5
RHU/MHC6
RHU/MHC7
Note: List other public lying-in/birthing clinic outside RHC/MHC

in your municipality and specify if MCP and NCP Accredited (X) LGU (X) LGU
w/o HFs w/o HFs
accredited accredited
Birthing/lying-in clinic 1 on 4 on 4
PhilHealth PhilHealth
Packages Packages
(X) LGU (X) LGU
w/o HFs w/o HFs
on 4 on 4
Packages Packages
Birthing/lying-in clinic 2
Birthing/lying-in clinic 3
TOTAL:
______ Quarter : ____________________
Accreditation MCP NCP TB-DOTS PCB 1 Accreditation
status status
(P) - LGU (P) - LGU

with HFs with HFs
for 4 for 4
Packages Packages
(X) LGU (X) LGU

w/o HFs w/o HFs
on 4 on 4
Packages Packages
(X) LGU (X) LGU
w/o HFs w/o HFs
on 4 on 4
Packages Packages
Indicator 38. % of municipalities/cities with at least The proportion of municipalities/cities with:

one public health facility accredited by PhilHealth 1.at least 1 public health facility accredited for Maternity Care Package (MCP);
for maternity care, newborn care package, TB- 2.at least 1 public health facility accredited for Newborn Care Package (NCP);
DOTS, and PCB 1 packages. 3.at least 1 public health facility accredited for TB-DOTS; and
4.at least 1 public health facility accredited for PCB package.
The four PhilHealth accreditation packages may not be confined in only one health facility in
(OP 1) the LGU.
MCP-accredited health facility: any hospital/RHU/ MHCs/ birthing/lying-in clinics which meets
PhilHealth accreditation requirements
NCP-accredited health facility: any hospital/RHU/ MHCs/ birthing/lying-in clinics which meets
PhilHealth accreditation requirements
TB-DOTS accredited health facility: any RHU/MHC/ HC/ BHSs which meets PhilHealth
accreditation requirements
PCB-accredited health facility: any RHU/MHC which meets PhilHealth Accreditation

requirements
C. Formula
Numerator: Number of municipalities and cities with at least one accredited public health facility for:
1.MCP;
2.NCP;
3.TB-DOTS;
4.PCB during a given period
Denominator: Total number of municipalities and cities
Multiplier: 100

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Module 1.

Data Collection Form at the RHU/MHC

Total no. of fully immunized

b. Modern FP Unmet Among NHTS plus other non-NHTS poor

c. Modern FP Unmet Need Among NHTS household members only

Proportion of WRA with

Indicator 9. 9.1 Based on TB Registry/ITIS, get the total number of NEW

Indicator 10. 10.1 Based on the Philippine Malaria Information System

Encircle the status

Name of DMO : ____________________

Encircle the status

per 100,000: _____________

Indicator 7. a. Modern FP Unmet Need Among Generral Population

b. Modern FP Unmet Among NHTS plus other non-NHTS poor

c. Modern FP Unmet Need Among NHTS household members only

Indicator 8. a. NHTS plus other non-NHTS poor

b. NHTS household members

% of poor provided with annual health check-

Tuberculosis incidence rate per 100,000

Malaria Prevalence per 100,00 population

Denominator: Total number of estimated eligible population

Denominator: Total number of deliveries

Numerator: Total number of deliveries in a health facility during a given period

Denominator: Total number of deliveries

Denominator: Total number of deliveries

Denominator: Total PSA projected population during a given period

Denominator: Total PSA projected population during a given period

Total no. of leprosy

(X) (P) MD RN RM (X) (P) MD RN RM (X) (P) MD RN RM (X) (P) MD RN RM

1 yes yes yes yes

% of health facilities with functional

% of barangays with at least

Numerator: Total number of leprosy cases during a given period

Denominator: Total PSA projected population during a given period

Numerator: Number of public health facilities 10,000

Denominator: Total number of public health facilities during a given period

Denominator: Total number of barangays during a given period

X - not achieved Proportion of

P - if with institutionalized DRRM - H % of barangays

19.2 Indicate the no. of households in your municipality/city.

Numerator: Total number of wasted children aged 0-59 months old

Numerator: Total number of stunted children aged 0-59 months old

Numerator: Number of LGHFs [Provincial/ City/ Municipal Health Offices, LGU-owned

. Encircle the status

due to NCDs per 100,000:

. Encircle the status

Death Rate due to

Neonatal Mortality Rate

Under-Five Mortality Rate

Maternal Mortality Ratio

Premature Mortality Rate due to

Indicator 32. Premature Mortality

Death Rate due to Road Traffic

0-28 days 1-11 months 12-59 months

For the Month of ______________________ (A) (B) (C) (D)

0-28 days 1-11 months 12-59 months

0-28 days 1-11 months 12-59 months

Total for the Year

" under Column 1. Ensure that the date of death is

ese below the " Hospitals" in Column1.

Get the total no. of Under-

Get the total no. of Under-

Get the total no. of Under-

For the Month of: