INDIVIDUAL PERFORMANCE COMMITMENT REVIEW (IPCR)

HUMAN RESOURCES FOR HEALTH DEPLOYMENT PROGRAM (HRH-DP) 2018

I, ______________________________________(NAME), Medical Technlogist Deployment Program (POSITION), _________________________ (AREA OF ASSIGNMENT), comm
deliver and agree to be rated on the attainment of the herein MFOs in accordance with their corresponding success indicators for the 1st semester (January - June) of 2018.

Name and Signature of Ratee

Date
Reviewed by: Approved by:

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Chief of Technical Date Provincial Health Officer I Date
Accomplishment Rating
Major Final Output (MFO) Remarks
Target Actual Percent Q E T Ave

1. No. of laboratry examinations performed. 360

2. No. of health information and dissemination in the community conducted. 24

3. % of functional equipments. 100%

4. No. of technical assistance of laboratory procedures provided. 6
5. No. of laboratory reports submitted to the Municipal Health Office / Provincial 6
Health Office
6. No of laboratory reports submitted to the Regional Office 2
Accomplishment Rating
Support to Operation (STO) Remarks
Target Actual Percent Q E T Ave
NTBR NTBR NTBR
General Administrative Success Indicator (Target + Elementary Accomplishment Rating
Remarks
Support Services (GASS) Measure) Period Target Actual Percent Q E T Ave
1. Submitted Daily Time Record 6 NTBR NTBR
2. Submitted Accomplishment 6 NTBR NTBR
 Final Average Rating:
Comments and Recommendation for Development purposes:

Discussed with: Assessed by: Final Rating

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Signature of Rate Date Chief of Technical Date Provincial Health Officer I Date
Legend: 1- Quality, 2-Efficiency, 3-Timeliness, 4-Average
MANCE COMMITMENT REVIEW (IPCR)
ALTH DEPLOYMENT PROGRAM (HRH-DP) 2018

ployment Program (POSITION), _________________________ (AREA OF ASSIGNMENT), commit to

with their corresponding success indicators for the 1st semester (January - June) of 2018.

Name and Signature of Ratee

Date

Remarks

Remarks

Remarks
 Final Rating

ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Date
 INDIVIDUAL PERFORMANCE COMMITMENT REVIEW (IPCR)
HUMAN RESOURCES FOR HEALTH DEPLOYMENT PROGRAM (HRH-DP) 2018

I, ______________________________________(NAME), Dentist Deployment Program (POSITION), _________________________ (AREA OF ASSIGNMENT), commit to deliver and agree to be rated
on the attainment of the herein MFOs in accordance with their corresponding success indicators for the 1st semester (January - June) of 2018.

Name and Signature of Ratee

Date
Reviewed by: Approved by:

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Chief of Technical Date Provincial Health Officer I Date

Accomplishment Rating
No. of
Major Final Output (MFO) Target Remarks
Health Actual Percent Q E T Ave
Indicators/
Reports

1. Basic Oral Health Care (BOHC)

1.1 12- 71 Months Old (Orally Fit Child)

a. No. of Orally Fit Male children 12- 71 months old examined. 45/qtr.

b. No. of Orally Fit Female children 12- 71 months old examined. 45/qtr.

1.2 12-71 months old with BOHC

a. No. of male children 12- 71 months old provided with Basic Oral Health Care (BOHC). 180/qtr.

b. No. of female children 12- 71 months old provided with Basic Oral Health Care (BOHC). 180/qtr.

1.3 Adolescent and Youth (10-24 years old) provided with Basic Oral Health Care (BOHC)

a. No. of Male Adolescent and Youth (10-24 years old) provided with Basic Oral Health Care (BOHC) 500/qtr.

b. No. of Female Adolescent and Youth (10-24 years old) provided with Basic Oral Health Care (BOHC) 500/qtr.

1.4 No. of Pregnant Women provided with Basic Oral Health Care (BOHC) 30/qtr.

1.5. Older Persons (60 years old and above) provided with Basic Oral Health Care (BOHC)

a. No. of Male Older Persons (60 years old and above) provided with Basic Oral Health Care (BOHC) 150/qtr.
b. No. of Female Older Persons (60 years old and above) provided with Basic Oral Health Care (BOHC) 150/qtr.

1.6 Other ages (6-9 years old and 25-59 years old) provided with any Basic Oral Health Care (BOHC) Services

a. No. of Male (6-9 years old) provided with any Basic Oral Health Care (BOHC) Services 500/qtr.

b. No. of Female (6-9 years old)provided with any Basic Oral Health Care (BOHC) Services 500/qtr.

c. No. of Male (25-59 years old) provided with any Basic Oral Health Care (BOHC) Services 500/qtr. NTBR

d. No. of Female (25-59 years old) provided with any Basic Oral Health Care (BOHC) Services 500/qtr.
Accomplishment Rating
Support to Operation (STO) Remarks
Target Actual Percent Q E T Ave

NTBR NTBR NTBR

Accomplishment Rating
General Administrative Support Services (GASS) Success Indicator (Target + Measure) Elementary Period Remarks
Target Actual Percent Q E T Ave

1. Submitted Daily Time Record (DTR) 6 NTBR NTBR

2. Submitted Accomplishment Report 6 NTBR NTBR

Final Average Rating:

Comments and Recommendation for Development purposes:

Discussed with: Assessed by: Final Rating

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Signature of Rate Date Chief of Technical Date Provincial Health Officer I Date
Legend: 1- Quality, 2-Efficiency, 3-Timeliness, 4-Average
 INDIVIDUAL PERFORMANCE COMMITMENT REVIEW (IPCR)
HUMAN RESOURCES FOR HEALTH DEPLOYMENT PROGRAM (HRH-DP) 2018

I, ____________________________(NAME), Nurse Deployment Program (POSITION), ___________________ (AREA OF ASSIGNMENT), commit to deliver and agree to be rated
on the attainment of the herein MFOs in accordance with their corresponding success indicators for the 1st semester (January - June) of 2018.

Name and Signature of Ratee

Date
Reviewed by: Approved by:

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Chief of Technical Date Provincial Health Officer I Date
Accomplishment Rating

No. of Target
Major Final Output (MFO) Health Remarks
Indicators/ Actual Percent Q E T Ave
Reports

1. No. of household health education conducted. 360

2. % of under 5 children with Diarrhea referred to health facilities. 100%

3. % of 12-59 months old moderately acute malnutrition (MAM) referred to health facility. 100%

4. % of 12-59 months old severe acute malnutrition (SAM) referred to health facility. 100%

5. % of eligible (6- 59 months old) children given Vitamin A capsule per household visited. 100%

6. % of EPI defaulter (12- 24 months old) per antigen followed-up and referred to health facility for 100%
immunization.

a. Penta 100%

b. OPV 100%

c. PCV 100%

d. MMR 100%
7. % of under 5 children with Respiratory Tract problems referred to health facilities. 100%

8. % of patients with more than 2 weeks of cough referred for sputum exam. 100%

9. % of TB patient lost to follow up and referred to health facilities. 100% NTBR

10. No. of women of reproductive age screened for VIA / Pap Smear in a health facility. 6 NTBR

11. % of hypertensive clients age 25 yrs and above in a barangay screened. 3%

12. % of diabetic clients age 25 yrs and above in a barangay screened. 1%

13. No. of smoker counselled 1

Accomplishment Rating
Support to Operation (STO) Remarks
Target Actual Percent Q E T Ave

1. % of Maternal Deaths reported. 100%

2. % of Neonatal Deaths reported. 100%

3. % of Infant Deaths reported. 100%

3. % of Under 5 years old Deaths reported. 100%

Success Indicator Elementary Accomplishment Rating

General Administrative Support Services (GASS) Remarks
(Target + Measure) Period Target Actual Percent Q E T Ave

1. Submitted Daily Time Record (DTR) 6 NTBR NTBR

2. Submitted Accomplishment Report 6 NTBR NTBR

Final Average Rating:

Comments and Recommendation for Development purposes:

Discussed with: Assessed by: Final Rating

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Signature of Rate Date Chief of Technical Date Provincial Health Officer I Date
 INDIVIDUAL PERFORMANCE COMMITMENT REVIEW (IPCR)
HUMAN RESOURCES FOR HEALTH DEPLOYMENT PROGRAM (HRH-DP) 2018

I, ______________________________________(NAME), Rural Health Midwife Placement Program (POSITION), _________________________ (AREA OF ASSIGNMENT),
commit to deliver and agree to be rated on the attainment of the herein MFOs in accordance with their corresponding success indicators for the 1st semester (January - June)
of 2018.

Name and Signature of Ratee

Date
Reviewed by: Approved by:

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Chief of Technical Date Provincial Health Officer I Date

Accomplishment Rating
Major Final Output (MFO) Remarks
Target Actual Percent Q E T Ave

1. Maternal Health Care

a. No. of household health education conducted. 360
b. % of pregnant women tracked.
- below 15 years old 100%
- 15-19 years old 100%
-20- 49 years old 100%
c. % of pregnant women with four antenatal care examined. 100%
d. % of pregnant women given 2 TT immunization. 100%
e. No. of facility based deliveries handled. 18
f. % of postpartum mothers initiated exclusive breastfeeding. 100%
g. % of mothers with two postpartum follow up visits done. 100% NTBR
h. % of high risk pregnant mothers referred. 100% NTBR
i.% of pregnant women with birth plan. 100%
2. Neonatal Health Care NTBR
a. No. of babies screened/ referred for newborn screening. 18
b. No. of babies given BCG vaccine. 18
b. No. of babies given Hepa- B vaccine. 18
c. % of eligible (6- 59 months old) children given Vitamin A capsule per household visited. 100%
d. % of EPI defaulter (0-11 months old) per antigen followed-up and referred to health
facility for immunization.
- BCG 100%
- Hepa-b 100%
- Penta 100%
- OPV 100%
- PCV 100%
- MMR 100%
f. % of Newborn Screening done or referred. 100%
3. Infant Health Care
a. No. of infant given OPV dose. 54/ sem.
b. No. of infant given Hepa B dose. 54/ sem.
c. No. of infant given Measles dose. 54/ sem.
4. Infant Nutrition
a. No. of 7 months old infant started complementary feeding. 100%
b. Percent of infant with moderately acute malnutrition (MAM) referred to health facility. 100%
c. Percent of infant with severe acute malnutrition (SAM) referred to health facility. 100%
Accomplishment Rating
Support to Operation (STO) Target Actual Percent Q E T Ave Remarks
NTBR NTBR NTBR
General Administrative Support Accomplishment Rating
Success Indicator (Target + Measure) Elementary Target Actual Percent Q E T Ave Remarks
Services (GASS) Period
1. Submitted Daily Time Record (DTR) 6 NTBR NTBR
2. Submitted Accomplishment Report 6 NTBR NTBR
Final Average Rating:
Comments and Recommendation for Development purposes:

Discussed with: Assessed by: Final Rating

Ma. GERALDINE A. MACAPEGES, MD.,MPH.,CESO ELIZABETH A. SAMAMA, MD.,MHM.,FPSMSI

Signature of Rate Date Chief of Technical Date Provincial Health Officer I Date
Legend: 1- Quality, 2-Efficiency, 3-Timeliness, 4-Average