MATERNAL AND CHILD HEALTH-RELATED (MCH) DATA FOR

ADOLESCENT AND YOUTH (10-29 YEARS OLD)

REPORTING FORM

PROVINCE OF RIZAL

1. MUNICIPALITY:
2. FACILITY NAME:

TANAY
WAWA BARANGAY HEALTH STATION

3. PERSONNEL IN CHARGE/ DESIGNATION:

4. FOR THE PERIOD:

MARBELYN A. CAPA/ RHM

Please be guided by the following instructions:

1.
Indicate the name of municipality/city. (e.g. City of Antipolo, Morong, etc.)
2.
Indicate the name of facility. (e.g. Cainta RHU I, San Mateo Rhu III, San Isidro BHS)
3.
Indicate the name of personnel in-charge of report preparation/consolidation. Also indicate designation of personnel. (e.g. Juan dela Cruz/PHN, Juan dela Cruz/RHM)
4.
Indicate the reporting period and year. Reporting period should be per quarter. (e.g. Jan-March 2015)
5.
For program indicators, fill in the data being asked by SEX (M/F) and by AGE GROUP (10-14, 15-19). Indicate zero (0) if NONE.
6.
For Source Data, put check under TCL if the data is based on Target Client List. Otherwise, indicate the source of data under OTHERS. (i.e. attendance sheet, logbook)

10-14 YEARS OLD

15-19 YEARS OLD

TOTAL

PROGRAM INDICATORS
M

1.
2.
3.

Number of adolescent and youth provided with

FP/RH counselling.
Number of pregnant adolescent and youth provided
with FP/RH information.
Number of adolescent and youth using any FP
method during this period.

12. Number of pregnant adolescent and youth who had

their first antenatal care during 1st trimester.
13. Number of adolescent and youth who gave birth
during this period.
14. Number of adolescent and youth who gave birth by
place of delivery

PILLS
INJECTA
BLE
IUD
CM
BBT
SDM
LAM
CONDO
M
IMPLAN
T

PILLS
INJECTA
BLE
IUD
CM
BBT
SDM
LAM
CONDOM
IMPLANT

PILLS
INJECTA
BLE
IUD
CM
BBT
SDM
LAM
CONDO
M
IMPLANT

RHU
HOSPITA
L
BHS
LYING-IN
HOME

RHU
HOSPITA
L
BHS
LYING-IN
HOME

RHU
HOSPITA
L
BHS
LYING-IN
HOME

SOURCE OF DATA
(others specify)
OTHER
TCL
S

OTHERS
20. Number of adolescent and youth who had fetal
death during this period.
Prepared by:
__________________________________
(Signature over Printed Name)

OTHERS

OTHERS