GETTING TO KNOW YOU BETTER SURVEY

The Department of Health cares for the welfare of its health workforce. In lieu of this, we would like to know
certain information about you and your current situation. Please answer the following questions as honestly as
you can. Your answers will help us in determining how we could best help you in your PARTICULAR
SITUATION.

The information I will provide below is correct. I understand

that this will remain confidential. Date signed:
(mm/dd/yyyy)
Signature:______________________________________

A. General Profile
Name Sex ☐M Civil ☐Single
___________________________________ ☐F Status ☐Married
(Last Name) (First Name) (M.I.) ☐Other:
________
Birthdate Age Contact
(mm/dd/yyyy) (years) Number

Municipality/City Email
District Region
Official Address Current ☐MHO
Position ☐RHP
☐DTTB
☐Other:
_______________________

Total Population ☐<5,000 No. of ☐< 1 year

Served ☐5,000-10,000 Years ☐1-3 years
☐10,001-30,000 in ☐3-10 years
☐>30,000 ☐10-20 years
Current
☐> 20 years
position

B. Competency Profile
Highest Educational Level ☐Medicine Degree Trainings ☐Residency: _________________
☐MPH Completed ☐Other(s):
☐Other:
______________________

C. Compensation Profile
Ave. Monthly Salary ☐<30,000 Ave. Monthly ☐< 5,000 Did you ☐None
Past 2 years (in Philhealth receive
☐5,000-10,000
pesos) ☐30,000-50,000 Capitation Magna Carta ☐Partial
Share past 2 ☐10,001- 20,000
Benefits past ☐Full
☐>50,000 years (in
☐20,001-50,000 2 years?
pesos)
☐>50,000
D. Services Offered
Programs No major Problematic but can be Highly
issues dealt with locally problematic and
needs higher
attention
Maternal, Newborn and Child Health & Nutrition
Family Planning
Tuberculosis
HIV/AIDS
Immunization
Adolescent Health
Non-communicable diseases
Other(s):

E. Service Delivery
What is the ave. monthly number of patients served?
Where do you refer patients?

What are the reasons you refer patients?

Which medicine supplies are usually inadequate?

Why are these inadequate?

Which laboratory tests is your facility able to do?

How many outreach medical mission(s) did you

undertake or participated in during the past 2 years?
Is your facility Sentrong Sigla compliant?
What is your total budget for 2017?

Do you have other

concerns/recommendations/suggestions you would like
us to know?

Thank you for answering.