Master List of Women of Reproductive Age for Family Planning Services

For the Quarter/Year: _____________________

Barangay: ___________________________ Name of BHS Midwife: ________________________________________ Date Prepared: _____________

No. HH No. Name of WRA Birthday If col 7b or 7c is WRA Based on TCL

Age in Do you plan to If col. 7b & 7c is √, √ and using col.
Address (MM/DD/ 8b or 8c, would with on FP, did WRA
Years YY) SE have more are you currently you like to shif
(FN, MI, LN) MFP accept any
Status children? (Place using any FP to Modern
method? Unmet modern FP
a √) method?
(Place a √) Need method?

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
15-19 20-49 1: NHTS Not using Yes No (Put √ if No Yes
If Yes, when? No If Yes, what type?
2: NonNHTS any FP (9a) (9b) Col 9a is (11a) (11b)
Now Spacing Limiting Modern Traditional Method checked) (Put Specify Date
(7a) (7b) (7c) (8a) (8b) (Place a a √) modern when FP
√) FP method
(8c) Method accepted
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
 Master List of Women of Reproductive Age for Family Planning Services
For the Quarter/Year: _____________________
19
TOTAL