` HSCMDA-Annex G

HSCMDA Service Delivery Event following MDA Masterlist (Recording form for STH,SCH and LF Areas)*

Region: ___________________Province/Division:____________________________ Municipality:________________________________

Service Deliver Outlet:

BHS:________________________________ School/Name of School:________________________________
RHU/Health Center ____________________ Others/Name: _______________________________________

Numbe Surname Given Age Sex Complete Time of Date of Intake of Drug Taken(check Signs and Time of Action
r Name in Address Intake of Drug(dd/mm/yy) what is applicable) Symptoms( onset of Taken
/middle Years M F Drug ALB DEC PAQ Adverse signs and
Initial events) symptoms
1 ABASTAS, JASON R 14 ∕ Dalama, 9:45 a
Tubod, LDN
2 ABELLA, JOSHUA PAUL M 13 ∕ Dalama,
Tubod, LDN
3 ALFECHE, LEUMAS S 14 ∕ Dalama,
Tubod, LDN
4 BATISLAONG, ERIE R 13 ∕ Dalama,
Tubod, LDN
5 CEBELLO, JAKE B 14 ∕
6 DAGPIN, CALVIN B 14 ∕ Dalama,
Tubod, LDN
7 EGAY, REYMOND L. 14 ∕
8 ENOY, ALLAN JAY P 14 ∕ Dalama,
Tubod, LDN
9 GALLEGO, SHERLIM A 14 ∕ Dalama,
Tubod, LDN
10 JUANICO, EDGAR 34 ∕ Dalama,
Tubod, LDN
11 LASCONIA, JULIE BOY Q 14 ∕ Dalama,
Tubod, LDN
12 LIMOAN, ARNEL JOY C 19 ∕ Dalama,
Tubod, LDN
13 PATONONGON, DANIEL 15 ∕ Dalama,
Tubod, LDN
14 QUERBO, LAURENCE 13 ∕ Dalama,
MARK M Tubod, LDN
15 MORATO, CHRISTIAN 14 ∕ Dalama,
DAVE Tubod, LDN
16 RIZARES, FREDERICK Q 13 ∕ Dalama,
Tubod, LDN
17 SARABELLO, CLERK C 13 ∕ Dalama,
Tubod, LDN
18 SUMIL, REY S 14 ∕ Dalama,
Tubod, LDN
19 SENINING, DEXTER A 13 ∕ Dalama,
Tubod, LDN
20 TANGIYAN, ANGELO A 13 ∕ Dalama,
Tubod, LDN
21 TANGIAN, LIM A 22 ∕ Dalama,
Tubod, LDN
22 ABADILLA, SHELLA G 14 ∕ Dalama,
Tubod, LDN
23 BANQUIL, MARY JANE E 13 ∕ Dalama,
Tubod, LDN
24 BARRIENTOS, JANET A 14 ∕ Dalama,
Tubod, LDN
25 CENCIO, REGINE L 13 ∕ Dalama,
Tubod, LDN
26 LIMOAN, RITCHELLE 15 ∕ Dalama,
JANE Tubod, LDN
27 LOREJO, MARY JOY A 13 ∕ Dalama,
Tubod, LDN
28 MAGLASANG, CHIARA 14 ∕ Dalama,
MAE R Tubod, LDN
29 PEPITO, IVIE G 13 ∕ Dalama,
Tubod, LDN
30 PEPITO, JONALYN B 13 ∕ Dalama,
Tubod, LDN
31 PONCE, RHEA LYN G 13 ∕ Dalama,
Tubod, LDN
32 SUMABANG, ABEGUEL S 14 ∕ Dalama,
Tubod, LDN
33 SUMIL, GEMMA S 13 ∕ Dalama,
Tubod, LDN
34 ROSAL, GENALYN O 14 ∕ Dalama,
Tubod, LDN
35 BATION, RUSSEL A 14 ∕ Dalama,
Tubod, LDN

___________________________________ ________________________________________
_______________________________
Person accomplishing this Report/Position Approved/Verified by Supervisor/Position
Date Accomplished (dd/mm/yy)

*To be filled up at the Service Delivery Sites where MDA takes place like Main Health Center (MHC), Barangay Health station or Center (BHS/BHC), Schools, Churches, Private
Clinis and other fixed sites (e.g. Church, Market Post and the like).
 HSCMDA-ANNEX G.2

HSCMDA Municipal/District/School District Adverse Event following MDA Reporting Form (For STH,Sch and LF Areas)*
for Mild and Moderate Cases

Region: Province: City/Municipality/School District:

Barangay/Schools Total Total Number
numbe Fever Headach Dizzines Nausea Vomiting Allergy Dia Abdomina Erratic Others
r of e s rrhea l Pain Worm (Indicate)
people Migration
who
ingest
drug
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
TOTAL

Accomplished by: Verified by: Date

Accomplished: _________________

Dd/mm/yy

__________________________________________ _________________________________________
Public Health Nurse/School District Nurse Municipal/District Health Officer/District Supervisor

*To be filled up at the Municipal/District Health Office/School District and to be submitted to the Provincial/City Health Office/School
Division
*To be submitted weekly every Tuesday but starting on the 2 nd Tuesday of July (July 12,2016) with the final report to be submitted to
PHO/CHO on the first Tuesday of August 2016.