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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

COMPLETE Name of Facility

Type of Health Facility

CODE COMPLETE Name of Facility Type of Health Facility appropriate box ) ( Please tick COMPLETE

appropriate box )

(Please tick

COMPLETE Address

Name of NBS Coordinator

) ( Please tick COMPLETE Address Name of NBS Coordinator Province/City   Government Hospital   Private

Province/City

tick COMPLETE Address Name of NBS Coordinator Province/City   Government Hospital   Private Hospital
tick COMPLETE Address Name of NBS Coordinator Province/City   Government Hospital   Private Hospital
 

Government Hospital

 

Private Hospital

Lying-in ClinicHealth Center

Lying-in Clinic Health Center

Health Center

Others (please specify) 

 
Health Center Others (please specify)   Contact Numbers _ Fax Numbers E-mail Address
Health Center Others (please specify)   Contact Numbers _ Fax Numbers E-mail Address

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 MONTH Deliveries Live Births Dissents Referred In-Born
Number of
Number of
Number of
Number of
MONTH
Deliveries
Live Births
Dissents
Referred
In-Born

% of NB Screened

Screened In-Borns

# of Live Births x 100

Outborn

Number of

Patients Who

Availed PHIC

NBS Package

Number of

Neonatal

Deaths

SIGNATURE OVER PRINTED NAME OF NSF COORDINATOR

DATE SIGNED

NOTE: The submission schedule will be as follows

NOTE: The submission schedule will be as follows

NOTE: The submission schedule will be as follows Monthly Census Reports January, February, March April, May,

Monthly Census Reports

January, February, March

April, May, June

July, August, September

October, November, December

Date of

Submission

Apr 15

Jul 15

Oct 15

Jan 15

Telephone: (045) 861-3428 Fax Number: (045)-861-3117

0942-978-0457

0956-736-4450

The accomplished report may be sent through courier, fax or e-mail. Kindly address to:

RD Leonita P. Gorgolon, MD, MHA, MCHM, CEO VI Attention: Janet T. Miclat, MD Phoebe Queen A. Pamintuan, RN/ Madeline Gayle T. Luzung, RN Department of Health - Regional Office 3 Diosdado Macapagal Government Center Maimpis, City of San Fernando, Pampanga

E-mail Address: nbs.dohro3@gmail.com

Kindly follow format for the subject: FACILITY CODE AND NAME OF THE FACILITY/HOSPITAL(all caps) and quarter (ex. 1234 OSPITAL NG PILAR 4th Quarter)