Performance (OPCR) (IPCR)

INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR)
I, ________________________________________, commit to deliver and agree to be rated on the attainment on the following targets in accordance with the indicated measures for the period _____________, __________
APPROVED BY: Signature of Head of Office

Name: 5 - Outstanding Date: _________________
Position: 4 - Very Satisfactory
3 - Satisfactory
2 - Unsatisfactory
1 - Poor
RATING
MAJOR FINAL OUTPUT SUCCESS INDICATOR (TARGETS+MEASURES) ACTUAL ACCOMPLISHMENTS REMARKS
Q T E AVE
1. Preparation of Annual Budget Proposal
100% of prepared annual budget proposal - income
Regular and Incom
and regular with complete supporting documents
submitted before June 15 of the current year.
2. Preparation of Obligation Documents
100% of obligation documents prepared accurately.
100% of collections and deposits accurately
3. Report of Collections and Deposits
reported daily.
100% employees personnel records updated
4. Updating of Employees Personnel Records
accurately every quarter.
TOTAL RATING
FINAL AVERAGE RATING
Rater comments and recommendations for Development Purposes or Rewards/Promotion
The above rating has been discussed with Supervisor

Name and Signature of Ratee: Name and Signature of Rater:
Position: Position:
Date: Date:
Final Rating by Office Head:

Position:
Date:
OFFICE PERFORMANCE COMMITMENT AND REVIEW (OPCR)
I, Thelma A. Gargantiel - Adm. Service - OIC of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the attainment on the following targets in accordance with the in
APPROVED BY: Signature of Head of Office

Name: 5 - Outstanding Date: _______________
Position: 4 - Very Satisfactory
3 - Satisfactory
2 - Unsatisfactory
1 - Poor
MAJOR FINAL OUTPUT SUCCESS INDICATOR ALLOTED DIVISIONS ACTUAL RATING

REMARKS
(TARGETS+MEASURES) BUDGET ACCOUNTABLE ACCOMPLISHMENTS Q T E AVE
7. Processing of PhilHealth and 100% of PhilHealth and PHINO claims

PHINO claims Completely process within sixty (60) days.
8. Repairs of Hospital Buildings 80% of repaired hospital building and

and Equipments equipment
SUPPORT FUNCTIONS
100% of individual Performance Commitment

1. Preparation and submission
and Review of adm. service staff prepared and
of Individual Performance
submitted thoroughly and completely every
Commitment and Review
month of May and Nov. of the year.
100% of adm. service staff DTR's prepared and

2. Preparation and submission
submitted accurately and completely done
of DTR
every end of the month.
100% of adm. service staff wore the prescribed

3. Wearing prescribed office
office uniform appropriately and completely
uniform
during duty hours.
10 availble adm. service staff on duty

4. Attendance to flag raising attended and participated actively during
retreat flag raising every Monday and flag retreat
every Friday
TOTAL RATING
FINAL AVERAGE RATING
Assessed by PMT Secretariat Reviewed by PMT Chairman Final Rating By:
Start of Rating Period End of Rating Period Start of Rating Period: End of Rating Period
Position: Position: Position: Position: Position:

Date Date Date Date
I, Thelma A. Gargantiel - Adm Service - OIC of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the attainment on the following
targets in accordance with the indicated measures for the period January to June 2015. QUINTIN C. BASCOS
APPROVED BY: QUINTIN C. BASCOS - Chief of Hospital I Chief of Hospital I
Name: Thelma A. Gargantiel 5 - Outstanding Date: ________________
Position: Adm. Service - OIC 4 - Very Satisfactory
3 - Satisfactory
2 - Unsatisfactory
1 - Poor
DIVISIONS ACTUAL RATING
MAJOR FINAL OUTPUT SUCCESS INDICATOR (TARGETS+MEASURES) ALLOTED BUDGET REMARKS
ACCOUNTABLE ACCOMPLISHMENTS Q T E AVE
100% of prepared annual budget proposal
1. Preparation of Annual Budget income and regular with complete supporting
Proposal - Regular and Income
documents submitted before June 15 of the
current year
2. Preparation of Obligation 100% of obligation documents prepared accurately
Document
3. Report of Collections and Deposits 100% of collections and deposits accurately

reported daily.
4. Updating of Employees Personnel 100% of employees personnel records updated

Records accurately every quarter.
80% of end user's request of goods and services

5. Procurement of Goods and Services acted upon accurately within two (2) days upon
receipt of request.
6. Maintenance of Medical Records 100% medical records completely maintained.
SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

SO/CF Formula: (total of all average ratings/no. of entires) x 90%
SF Formula: (total of all average ratings/no. of entires) x 10%
Comments and Recommendation for Development Purpose:
Assessed by: Date Reviewed by: Date: Final Rating by: Date:
Planning Office PMT Head of Office
Support Functions
100% of Individual Performance Commitment
1. Preparation and submission of and Review of adm. service staff prepared
individual Performance and submitted thoroughly and completely
Commitment and Review every month of May and November of the
year
2. Preparation and submission of 100% of adm. service staff DTRs prepared

DTR and submitted accurately and completely
done every end of the month
100% of adm. service staff wore the
prescribed office uniform appropriately and
uniform
completely during duty hours
10 available adm. service staff on duty

4. Attendance to flag raising and attended and participated actively during
flag retreat flag raising every Monday and flag retreat
every Friday

SO/CF Formula:(total of all average ratings/no. of entrie) x 90%
SF Formula:(total of all average ratings/no. of entrie) x 10%
Discussed: Date: Assessed by: Date: Reviewed by: Date: Final Rating by: Date
MELINDE T. SINGCO QUINTIN C. BASCOS,MD

Ratee Supervisor PMT Head of Office
I, MELINDE T. SINGCO, Medical Social Welfare of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
attainment of the following targets in accordance with the indicated measures for the period January to June 2015.
MELINDE T. SINGCO
Ratee
Date: ________________________
Reviewed by: Approved by:
THELMA A. GARGANTIEL QUINTIN C. BASCOS, MD

Adm. Service-OIC Date Chief of Hospital I Date
Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
SUCCESS INDICATORS Actual Rating*ory
MFO/PAP Remarks
(TARGETS + MEASURES) Accomplishments/Expenses Q E T 1 - PoorA
Core Functions
100% maked interview and socio-financial
1. Makes interview and socio-
evaluation effectively with patients referred
financial evaluatin - casework
with social, emotional problems which affect
process
medical situation daily
100% effectivley participated in the eligibility

2. Eligibility study for patients
study of pts admitted and discharge according
qualification
to their ability to pay daily
100% reffered patients to other welfare

3. Refers services to welfare
agencies accurately and effectively for further
agencies
assistance as necessary
Strategic Objectives
Support Functions
year

uniform

every Friday

QUINTIN C. BASCOS,MD
I, SECURITY GUARD of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% protected and safeguared effectively life

1. Protects and safeguards and properties with in the hospital vicinity
during tour of duty
100% cooperated hospital personnel in their

2. Cooperates hospital personnel needs sufficiently and effectively in their needs
during tour of duty
100% maintained peace and order effectively

3. Maintains peace and order
within hospital vicinity during tour of duty
Support Functions
year

uniform

every Friday

QUINTIN C. BASCOS,MD
I, SERVILLA D. LAXINA, Medical Technologist II of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
SERVILLA D. LAXINA
Ratee
Date: ________________________

Adm. Service-OIC Date Chief of Hospital Date
Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% performed laboratory examinations and
1. Performs laboratory procedures such as chemistry, hematology,
examinations and procedures parasitology, bacteriology and others
accurately accomplished as requested
100% of monthly laboratory reports prepared

2. Prepares monthly laboratory
and submitted every 15th day of the following
report
month
100% patients laboratory examinations and

3. Records patients laboratory
procedures recorded in the laboratory logbook
examinations and procedures
daily
Support Functions
year

uniform

every Friday

GUILLERMO R. ESONA, JR QUINTIN C. BASCOS,MD

I, GUILLERMO R. ESONA JR, Casual Plantilla - Carpenter of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
GUILLERMO R. ESONA, JR,

Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% maintained and repaired filling cabinets
1. Maintains and repair cabinets
and chairs accurately and effectively as
and chairs
necessary
100% repaired clogged comfort rooms and

2. Repairs comfort rooms toilet fittings a accurately and effectivel as
necessary
100% repaired leaking ceiling and glutter of

3. Repairs leaking ceiling and
hospital buildings accurately and effectively as
gutter
necessary
Support Functions
year

uniform

every Friday

RONALD M. ALVARICO, DDM QUINTIN C. BASCOS,MD

I, RONALD M. ALVARICO, Dentist II of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
RONALD M. ALVARICO, DDM

Ratee
Date: ________________________
QUINTIN C. BASCOS, MD QUINTIN C. BASCOS, MD

Chief of Hospital I Date Chief of Hospital I Date
Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% performed tooth extraction effectively

1. Performs tooth extractions
and efficiently daily
2. Performs oral examinationS out 100% performed oral examinations to out and
and in-patients in- patients effectively daily
3. Gives chairside dental health 100% gave chairside dental health education
educaction accurately and effectively daily
Support Functions
year

uniform

every Friday

NEDIE AGADER QUINTIN C. BASCOS,MD

I, NEDIE AGADER, Casual Plantilla - Food Service Worker of the Dietary Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
NEDIE AGADER
Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% of prepared food assisted in the dishing
1. Assists in the preparation of out and distribution of food to in-patients and
food - dish out and distribute doctors 24 hours on duty sufficiently and
completely 3 meals per daily
100% of used food trays collected completely

2. Collects food trays
30 minutes after serving
100% maintained cleanliness and washed food

3. Maintains cleanliness and wash
trays, kitchen utensils in the dietary
utensils in the dietary department
department fully and entirely daily
Support Functions
year

uniform

every Friday

CHARIE MAE P. CALIJAN QUINTIN C. BASCOS,MD

I, CHARIE MAE P. CALIJAN, NUTRI/DIETITIAN II, of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
CHARIE MAE P. CALIJAN

Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% planned menu for therapeutic and regular

1. Plans menu for patients and
diet for patients and hospital function
doctors
accurately daily
100% followed-up diet counseling to in-patient

2. Follow-ups diet counsel to in-
with therapeutic and regular diets to in-patients
patients
accurately and efficiently daily
100% of the admitted patients recorded

3. Records in-patients subsisted accurately in the in-patients subsisted logbook
daily
100% purchased foodstuff for patients and

4. Purchases of Foodstuff doctors consumption accurately and sufficiently
daily
100% cash advances accurately and completely

5. Liquidates cash advances
liquidated 5 days before due date
Support Functions
year

uniform

every Friday

ELIZABETH P. MENDOZA QUINTIN C. BASCOS,MD

I, ELIZABETH MENDOZA, COOK I, of Dietary Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
ELIZABETH MENDOZA
Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
1. Cook meals according to plan

menu
- Cook meals for regular and 100% cooked regular and therapeutic diets
therapeutic diet accurately and sufficiently for in-patients daily
- Cook meals for doctors on 24 100% cooked meals sufficiently and accurately
hours duty for doctors 24 hours on duty daily
2. Prepares list of foodstuff for 100% prepared list of foodstuff for marketing
marketing accurately and sufficiently daily
Support Functions
year

uniform

every Friday

LANIE AGUILAR QUINTIN C. BASCOS,MD

I, LANIE AGUILAR, MEDICAL EQUIPMENT TECHNICIAN II, of Bais District Hospital, Bais City, commit to deliver and agree
to be rated on the attainment of the following targets in accordance with the indicated measures for the period January to June 2015.
LANIE AGUILAR
Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% performed x-ray procedures to in and out

1. Performs x-ray procedures patients effectively and accurately as requested
by the physicians daily
100% prepared developed film accurately for

2. Prepares develop film
reading to the radiologist daily
100% prepared and diluted developing solution

3. Prepares/dilutes solution
accurately for x-ray use daily
100% maintained and adjusted x-ray machine

4. Maintains and adjust x-ray
with preventive measures accurately and
machine
effectively daily
Support Functions
year

uniform

every Friday

JOHANNA CALUMPANG QUINTIN C. BASCOS,MD

I, JOHANNA CALUMPANG, Pharmacist II of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
JOHANNA CALUMPANG
Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% dispensed drugs and medicines
1. Dispenses drugs and medicines accurately and sufficiently as per prescription
daily
100% prepared requisition request accurately

2. Prepares requisition for drugs
and sufficiently for drugs and medicines every 3
and medicines
months
100% prepared medicine charges for

3. Prepares medicine charges PhilHealth, pay, charity patients accurately for
office billing daily
100% accurately recorded medicines

4. Records and files medicine
prescriptions dispensed in the logbook and filed
prescriptions
in the filling cabinet
Support Functions
year

uniform

every Friday

THELMA A. GARGANTIEL QUINTIN C. BASCOS,MD

SUCCESS INDICATORS Actual Rating*
MFO/PAP Remarks
(TARGETS + MEASURES) Accomplishments/Expenses Q E T A
f. Processing of PhilHealth and
100% medical records completely maintained
PHINO claims
g. Repair of hospital buildings

80% of repaired hospital buildings and
and equipment's - per annual
equipments as per approved annual budget
budget
100% of prepared annual budget proposal -

2. Preparation of annual budget income and regular with complete supporting
proposal - regular and income documents submitted before June 13 of the
current year
3. Updating of employees 100% employees personnel records updated

personnel records accurately every quarter
100% employees under administrative service

4. Evaluation IPRC of
accurately and effectively evaluated by
administrative staff
semester
5. Attendance of meeting and 100% attended meetings and staff

staff development development accurateley as scheduled.
I, - Administrative Service - OIC of Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
THELMA A. GARGANTIEL
Ratee
Date: ________________________
QUINTIN C.BASCOS, MD QUINTIN C. BASCOS, MD

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
1. Supervision of activities of the
admin personnel
a .Preparation of obligation 100% of obligation documents prepared

documents accurately
b. Reports of collection and 100% of collections and deposits accurately

deposits reported daily
c. Maintainance of the motor

100% maintained the motor vehicle,
vehicle, conveyance of and
conveyance of and transportation of hospital
transportation of hospital official
official and personnel with destination and
and personnel with destinatio and
supplies accurately daily
supplies
80% of end user's request of goods and

d. Procurement of goods and
services acted upon accurately within tw0 (2)
services
days upon receipt of request
100% Medical Records maintained effectively

e. Maintenance of medical
and accurately with proper filling and
records
safekeeping daily.
Support Functions
year

uniform

every Friday

FE P. JAPIN QUINTIN C. BASCOS,MD

I, FE P. JAPIN, Utility Worker - Laundry Worker of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
FE P. JAPIN
Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% washed dirty linens, gowns, bedsheets,
1. Wash dirty linens, gowns, bed
rubber sheets and others accurately and
sheets, rubber sheets and others
effectively daily
100% ironed clean linens, gowns, bedsheet,

2. Iron clean linens rubber sheets and others accurately and
effectively daily
100% indorsed clean linens, gowns, bedsheet,

3. Indorses clean linens and
rubber sheets and other accurately to the
others
nurses station daily
100% collected accurately dirty linens, gowns,

4. Collects dirty linens and others
bedsheet, rubber sheets and others daily
Support Functions
year

uniform

every Friday

HERMOSA TOSOY QUINTIN C. BASCOS,MD

I, , Storekeeper II - Designated of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
HERMOSA P. TOSOY
Ratee
Date: ________________________

Rating 5-
Scale Outstanding
4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfact
MFO/PAP Remarks
Core Functions
100% procurement of hospital and office
1. Procures hospital and office supplies acted upon accurately and sufficiently
supplies based on end user's classification within two (2)
days upon reciept of request
100% of obligation documents accurately

2. Preparation obligation
prepared for payments of hospital and office
documents
supplies
100% storeroom custody of medical supplies

3. Custody of storeroom
and office supplies accurately and completely
100% of deliveries of hospital and office

4. Receives, counts, inspects and supplies accurately and completely received,
reject deliveries of supplies counted, inspected and rejected based on
specific classification
100% recommended and coordinated for the

5. Dispose of unserviceacble
disposal of unserviceable properties and waste
properties and materials
materials
Support Functions
year

uniform

every Friday

EMMANUEL PANGANIBAN QUINTIN C. BASCOS,MD

I, EMMANUEL PANGANIBAN, Bldg. Maintenance Man of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
EMMANUEL PANGANIBAN
Ratee
Date: ________________________

Adm. Service-OIC Date Chief of Hospital
RatinI Date
g
5-
Outstanding
4- Very
Scale Satisfactory
3-
Satisfactory
2-
Unsatisfactor
y
MFO/PAP 1T- Poor A Remarks
(TARGETS + MEASURES) Accomplishments/Expenses Q E
Core Functions
100% conducted regular inspections
1. Conducts regular inspection accurately and effectively of hospital
facilities, buildings and equipments daily
100% supervised accurately and

2. Supervises all repairs and effectively all repairs and maintenance
maintainance works on hospital facilities and submitted
accomplished reports as needed
100% operation effectively autoclave

3. Operates autoclave machine machines for sterilization of OR, ER, dental
supplies once a week
3. Wearing prescribed office uniform office uniform appropriately and completely
during duty hours

4. Attendance to flag raising and flag attended and participated actively during flag
retreat raising every Monday and flag retreat every
Friday

JAIME A. TINGSON QUINTIN C. BASCOS, MD

I, JAIME A. TINGSON, Driver of the Adm. Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
Ratee
Date: ________________________

Rating
5-
Outstanding
Scale 4- Very
Satisfactory
3-
Satisfactory
2-
Unsatisfactor
y
MFO/PAP 1T- Poor A Remarks
(TARGETS + MEASURES) Accomplishments/Expenses Q E
Core Functions
100% conveys or transport hospital official and
1. Drives official vehicle personnel on official vehicle safely to their
destinations on official business as needed
100% conducted preventive maintenanced and

conditioned official vehicles fully
2. Conducts preventive
passed/lubricated, watered in sound mechanical
maintenance on official vehicle
condition, checked brake and tires to be certain
that in good conditioned daily
Support Functions
1. Preparation and submission of
individual Performance
month of May and November of the year
100% of adm. service staff DTRs prepared and

2. Preparation and submission of DT submitted accurately and completely done
every end of the month
I, MARGA T. VILLAFLORES, Utility Worker I - Detailed as Clerk, Adm. Service of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
Ratee
Date: ________________________

Rating
5 - Outstanding
4- Very
Scale Satisfactory
3- Satisfactory
2-
Unsatisfactory
1 - Poor
SUCCESS INDICATORS Rating*
MFO/PAP Actual Accomplishments/Expenses Remarks
(TARGETS + MEASURES) Q E T A
Core Functions
100% of discharged patients billed
1. Takes charge in billing of discharge
accurately and completely upon
patients
discharged
100% received daily hospital

2. Receives hospital collections/
collections/payments accurately and
payments from patients due for
completely from patients due for
discharge and OPD patients
discharged and OPD patients.
Support Functions
100% of Individual Performance
1. Preparation and submission of Commitment and Review of adm. service
individual Performance Commitment staff prepared and submitted thoroughly
and Review and completely every month of May and
November of the year
100% of adm. service staff DTRs prepared

2. Preparation and submission of DTR and submitted accurately and completely
during duty hours

Friday

MARGA T. VILLAFLORES QUINTIN C. BASCOS, MD

during duty hours

Friday

VERA SYGACO QUINTIN C. BASCOS,MD

Ratee Supervisor PMT Chief of Hospital I
I, VERA SYGACO, Clerk I of the Adm. Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
VERA V. SYGACO
Ratee
Date: ________________________

Rating
5 - Outstanding
4- Very
Scale Satisfactory
3- Satisfactory
2-
Unsatisfactory
1 - Poor
Core Functions
1. Records patients admission and 100% patients admitted and discharged
discharge accurately recorded in the logbook daily.
100% of prepared mandatory hospital monthly

2. Prepares mandatory hospital
reports completely and accurately submitted
monthly reports
every 5th day of the following month.
100% of prepared hospital annual statistical

3. Prepares hospital annual
report submitted on the 15th day of the
statistical report
following year
Support Functions
individual Performance

2. Preparation and submission of DT submitted accurately and completely done
I, _MARIA CARMEN A. ASKIN, Nursing Attendant I detailed as Clerk of the Adm. Service Department of Bais District Hospital, Bais City, commit to deliver and on
the gree to be rated attainment of the following targets in accordance with the indicated measures for the period January to June 2015.
MARIA CARMEN A. ASKIN

Ratee
Date: ________________________

Rating
5 - Outstanding
4- Very
Scale Satisfactory
3- Satisfactory
2- Unsatisfactory
1 - Poor

Core Functions
100% of processed PhilHealth claims with
complete supporting papers filed and
1. Process PhilHealth claims
transmitted within 30 days upon
discharged.
100% of philhealth claims filed and
2. Records Philhealth claims transmitted accurately recorded in the
logbook a day before transmission.
Support Functions
individual Performance staff prepared and submitted thoroughly
Commitment and Review and completely every month of May and

uniform

4. Attendance to flag raising and attended and participated actively during flag
flag retreat raising every Monday and flag retreat every
Friday

MARIA CARMEN A. ASKIN QUINTIN C. BASCOS

Support Functions


2. Preparation and submission of DTRand submitted accurately and completely

3. Wearing prescribed office uniform prescribed office uniform appropriately and

every Friday

ANGIE CUI NINFA A. PINILI QUINTIN C. BASCOS

I, ANGIE CUI, NURSE II of the Nursing Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated
on the attainment of the following targets in accordance with the indicated measures for the period January to June 2015.
ANGIE CUI
Ratee
Date: ________________________
NINFA A. PINILI QUINTIN C. BASCOS, MD

Nurse IV Date Chief of Hospital I Date
Rating 5 - Outstanding
Scale 4- Very Satisfactory
3- Satisfactory
2- Unsatisfactory
1 - Poor
SUCCESS INDICATORS (TARGETS + Actual Rating*

MFO/PAP Remarks
MEASURES) Accomplishments/Expenses Q E T A
Core Functions
100% of all nursing activities in the ward, LR-DR and ER
1. Supervision of all activities in the
supervised accurately and safely based on Nursing
Ward, ER and LR-DR
Service Staff Performance Checklist during tour of duty
2. Documentation and Submission
a. Consolidation 100& of monthly hospital reports on OPD patients
and submission of monthly hospital consolidated and submitted accurately and completely
reports on OPD patients based on standard DOH forms every end of the month
consultation
100% of bi-monthly nursing staff schedules prepared
3. Preparation and submission of bi-
and submitted accurately and completely based on
monthly schedule of nursing service
standard staffing pattern of DOH done every 10th and
staff
25th of the month
100% of nursing service staff performance evaluated

4. Evalutation of performance of accurately and thoroughly based on Patient Satisfaction
nursing service staff Survey every month of July of same year and January of
the following year
Support Functions




every Friday

BETHZAIDA RODRIGUEZ NINFA A. PINILI QUINTIN C. BASCOS

I, BETHZAIDA RODRIGUEZ, NURSE II of the Nursing Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated
BETHZAIDA RODRIGUEZ
Ratee
Date: ________________________

3- Satisfactory
2- Unsatisfactory
1 - Poor
SUCCESS INDICATORS (TARGETS + Actual Rating*

MFO/PAP Remarks
MEASURES) Accomplishments/Expenses Q E T A
Core Functions
100% of all nursing activities in the OPD and OR
1. Supervision of nursing activities
supervised accurately and safely based on Nursing
in the OPD, and OR
Service Staff Performance Checklist during tour of duty
2. Documentation and Submission
a. Consolidation 100& of monthly hospital reports on OPD patients
and submission of monthly hospital consolidated and submitted accurately and completely
reports on OPD patients based on standard DOH forms every end of the month
consultation
100% of bi-monthly nursing staff schedules prepared
3. Preparation and submission of bi-
and submitted accurately and completely based on
monthly schedule of nursing service
standard staffing pattern of DOH done every 10th and
staff
25th of the month
100% of nursing service staff performance evaluated

4. Evalutation of performance of accurately and thoroughly based on Patient Satisfaction
nursing service staff Survey every month of July of same year and January of
the following year
Support Functions




every Friday

SHERA MAE UZARRAGA NINFA A. PINILI QUINTIN C. BASCOS

I, SHERA MAE UZARRAGA , NURSE I of the Nursing Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated
SHERA MAE UZARRAGA

Ratee
Date: ________________________

Rating
5 - Outstanding
4- Very Satisfactory
Scale 3- Satisfactory
2- Unsatisfactory
1 - Poor

Core Functions
100% of individual patient care needs
provided adequately and safely based on
1. Provision of nursing care
Nursing Service Staff Performance Checklist
(NSSPC) for Nurses during tour of duty
100% of patients oriented and informed

adequately and safely based on policies
2. Health Education
and Guidelines of the hospital during tour of
duty
100% of nursing records and reports

documented and endorsed properly and
3. Documentation of nursing care
completely based on Quality Assurance
Checklist during tour of duty
Support Functions

individual Performance Commitment
and Review

2. Preparation and submission of DTR submitted accurately and completely done

during duty hours

Friday

CHARLITO A. TAG-AT NINFA A. PINILI QUINTIN C. BASCOS

I, CHARLITO A. TAG-AT, UTILITY WORKER II of the Nursing Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated
CHARLITO A. TAG-AT
Ratee
Date: ________________________
NINFA A. PINLI QUINTIN C. BASCOS, MD

Nurse IV Date Chief of Hospital I
Ratin Date
g
5 - Outstanding
4- Very
Satisfactory
2- Unsatisfactory
1 - Poor

MFO/PAP Remarks
Core Functions
100% of assigned patients provided with direct
1. Provision of direct patient care care correctly and thoroughly based on NSSPC
for Nas during tour of duty
100% of assigned rooms/station cleaned and

2. Housekeeping
free from odor and orderly during tour of duty
100% of expected report/record documented

3. Documentation accurately and completely based on
record/report checklist during tour of duty
100% of oxygen tanks available, equipment,

4. Endorsement and maintenance
and other supplies endorsed properly and
of oxygen tanks available,
adequately based on endorsement logbook
equipment and other supplies
during tour of duty
Support Functions
year

and submitted accurately and completely
DTR

uniform

Friday

ROBERTO T. WONG QUINTIN C. BASCOS,MD

I, ROBERTO T. WONG, CASHIER I, ADMINISTRATIVE SERVICE of Bais District Hospital, Bais City, commit to deliver and agree to be rated
Ratee
Date: ________________________

Rating
5 - Outstanding
2- Unsatisfactory
1 - Poor

MFO/PAP Remarks
Core Functions
100% cash advanced and withdrawals for
1. Makes cash advances and
salaries and wages made accurately during
withdrawals
period covered
100% prepared report of collections and
2. Prepares report of collections and
accurately deposited to the designated
deposits
depository bank daily
100% custody of hospital funds accurately

3. Custody of hospital funds
kept in the safe-deposit box daily
100% disbursed/paid salaries, wages, valid

4. Disburses/pays salaries, wages,
claims and vouchers accurately during period
valid claims and vouchers
covered
100% cash advanced accurately liquidated 5

5. Liquidation of cash advance
days before due date
Support Functions
year

and submitted accurately and completely
DTR

uniform

Friday

ZINNIA MAY R. CRUZ QUINTIN C. BASCOS,MD

I, JUANITO T. TIU,MEDICAL OFFICER III of the Medical Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated
Ratee
Date: ________________________

Rating
5 - Outstanding
2- Unsatisfactory
1 - Poor

MFO/PAP Remarks
Core Functions
100% - examined and treated out and in-
1. Examines, diagnoses, treats
patients effectively and efficiently during tour
patients- Out and In-patiens
of duty
100% of minor surgical procedures performed
2. Performs surgical procedures
effectively and efficiently during tour of duty
100% of in-patients clilnical record accurately
3. Prepares and complete clinical
prepared and completed based on standard
records of in-patients
medical chart within 24 hours
4. Conducts daily ward work and 100% accurately conducted daily ward work
daily rounds and rounds within tour of duty
100% medico-legal patients effectively and

5. Attend medico-legal patients and efficiently attended during tour of duty and
court hearings accurately answered court hearings as per
subpoena
Support Functions
year

uniform

Friday

MARIBEL LLANERA NINFA A. PINILI QUINTIN C. BASCOS

I, MARIBEL LLANERA, NURSING ATTENDANT II of the Nursing Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated
MARIBEL LLANERA
Ratee
Date: ________________________
QUINTIN C. BASCOS,
NINFA A. PINILI MD
Rating
5 - Outstanding
4- Very
Scale Satisfactory
3- Satisfactory
2- Unsatisfactory
1 - Poor
SUCCESS INDICATORS (TARGETS Actual Rating*

MFO/PAP Remarks
+ MEASURES) Accomplishments/Expenses Q E T A
Core Functions
100% of assigned patients provided with direct
1. Provision of direct patient care care correctly and thoroughly based on NSSPC for
Nas during tour of duty
100% of assigned rooms/station cleaned and free

2. Housekeeping
from odor and orderly during tour of duty
100% of expected report/record documented

3. Documentation accurately and completely based on record/report
checklist during tour of duty
4. Endorsement and maintenance 100% of emergency medicines, equipment,

of emergency medicines, linens, instruments and other supplies endorsed
equipment, linens, instruments and properly and adequately based on endorsement
other supplies logbook during tour of duty
during duty hours

Friday

CF Formula:(total of all average ratings/no. of entrie) x 90%

I, ________________________________, LAUNDRY WORKER of the Adm. Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the
Ratee
Date: ________________________

3- Satisfactory
2- Unsatisfactory
1 - Poor

Core Functions
1. Preparation/Endorsement of clean 100% of clean linens/supplies/materials for

linens/supplies/materials for patients' patients' use prepared and endorsed properly
use and adequately based on NSSPC for Laundry
Workers during tour of duty
All laundry areas cleaned and disinfected
2. Housekeeping thoroughly and free from odor during tour of
duty
Support Functions
individual Performance Commitment
and Review

I, THELMA A. GARGANTIEL , head of the Adm. Service Department of Bais District Hospital, Bais City, commit to deliver and agree to be rated on the attainment of the
following targets in accordance with the indicated measures for the period January to June 2015.

3- Satisfactory
2- Unsatisfactory
1 - Poor
Allotted Rating*
Individual/s Actual
SUCCESS INDICATORS Budget for
MFO/PAP or Divisions Accomplishments/ Remarks
(TARGETS + MEASURES) 2014
Accountable Expenses Q E T A
(whole year)
Strategic Objectives/Core Functions
100% of prepared annual budget proposal
1. Preparation of Annual Budget income and regular with complete supporting
Proposal - Regular and Income documents submitted before June 15 of the
current year.
100% of obligation documents prepared

2. Preparation of Obligation Document
accurately.
100% of collections and deposits accurately

3. Report of Collections and Deposits
reported daily.
4. Updating of Employees Personnel 100% of employees personnel records updated

Records accurately every quarter.
80% of end user's request of goods and

5. Procurement of Goods and Services services acted upon accurately within two (2)
days upon receipt of request.
6. Maintenance of Medical Records 100% medical records completely maintained.

7. Processing of PhilHealth and PHINO 100% PhilHealth and PHINO claims completely
claims proces with in sixty (60) days.
8. Repairs of Hospital Buildings and 80% of repaired hospital building and

Equipments equipment.
Support Functions
100% of individual Performance Commitment
Individual Performance Commitment
and Review
month of May and Nov. of the year.
100% of adm. service staff DTR's prepared and

every end of the month.

during duty hours.
10 availble adm. service staff on duty attended

4. Attendance to flag raising retreat and participated actively during flag raising
every Monday and flag retreat every Friday.

Planning Office PMT (all members will sign/initial) Head of Office

5. Development of policies and procedures 3-4 policies/procedures developed
adequately and thoroughly per
grading period
6. Supervision/implementation of activities 95% of activities of SIAZAM ILHZ
of SIAZAM ILHZ superivised adequately and
thoroughly based on SIAZAM ILHZ
Work and Financial Plan for CY 2015
Support Functions
1. Preparation and submission of individual 100% of individual Performance
Performance Commitment and Review Commitment and Review of nursing
service staff prepared and submitted
thoroughly and completed every
month of May and November of the
year
2. Preparation and submission of DTR 100% of nursing service staff DTRs
prepared and submitted accurately
and completely done every end of the
month
3. Wearing prescribed office uniform 95% of nursing service staff wore the
prescribed office uniform
appropriately and completely during
duty hours
4. Attendance to flag raising and flag retreat
10 available nursing service staff on
duty attended and participated
actively during flag raising every
Monday and flag retreat every Friday

Assessed by: Date Reviewed by: Date Final Rating by: Date
Planning Office PMT Head of Office

I, QUINTIN C. BASCOS, MD, CHIEF OF HOSPITAL I, of the Bais District Hospital, Bais City, commit to deliver and agree to be rated on the attainment of the
Date QUINTIN C. BASCOS, MD Date

Chief of Hospital I
3- Satisfactory
2- Unsatisfactory
1 - Poor
Allotted Budget Individual/s or Actual Rating*

SUCCESS INDICATORS
MFO/PAP for 2014 Divisions Accomplishments/ Remarks
(whole year) Accountable Expenses
1. Supervision of all activities of the Hospital
a. medical examination and treatment
b. implementation of nursing care 95% of hospital activities supervised
c. various ancillary services accurately and thoroughly based on
c.1 Dietary services hospital staff performance checklist of
c. 2 Pharmacy individual staff
c. 3 Laboratory/X-ray
c. 4 Dental
2. Evaluation of performance of hosptal staff: 95% of hospital staff performance
a. Nursing Service Staff evaluated accurately and thoroughly
based on patients' satisfaction survey
b. Medical/Ancillary Staff every month of May and November of
c. Administrative Staff the year
6 meetings and 4 staff development

attended, represented and supervised
3. Representation/Provision/Attendance to adequately informed and updated with
meetings and staff development certificate of attendance per grading
period
4. Approval and submission of various reports, 100% of various reports approved and
leaves, DTRs and accomplishment reports submitted
Support Functions
1. Preparation and submission of Individual 100% of Individual Performance
Performance Commitment and Review Commitment and Review of nursing
service staff prepared and submitted
thoroughly and completely every
month of May and November of the
year
2. Preparation and Submission of DTR 100% of nursing service staff DTRs
perpared and submitted accurately
and completely done every end of the
month.
3. Wearing prescribed office uniform 100% of nursing service staff wore
the prescribed office uniform
approprietely and completely during
duty hours.
4. Attendance to flag raising and flag retreat 10 available nursing service staff on
duty attended and participated
actively during flag raising every
Monday and flag retreat every Friday.


Planning Office PMT (all members will sign/initial) Head of Office
I, NINFA A. PINILI, Nurse IV of the Nursing Service Department of the Bais District Hospital, Bais City, commit to deliver and agree to be rated on the attainment of the
QUINTIN C. BASCOS, MD Date QUINTIN C. BASCOS, MD Date

Chief fof Hospital I Chief of Hospital I
3- Satisfactory
2- Unsatisfactory
1 - Poor
Allotted Budget Individual/s or Actual Rating*

SUCCESS INDICATORS
MFO/PAP for 2014 Divisions Accomplishments/ Remarks
(TARGETS + MEASURES)
(whole year) Accountable Expenses Q E T A
1. Supervision of all activities of Nursing
Service
a) Implementation of Care 100% of nursing activities supervised
b) Endorsement/Evaluation of Nursing Care accurately and thoroughly based on
Nursing service staff performance
c) Documentation
checklist of individual nurse, nursing
d) Housekeeping attendant, IW and volunteers
e) Ensure adequate stocks of supplies,
materials/equipment for patients' use
100% of nursing service staff
2. Evaluation of performance of Nursing performance evaluated based on patient
Service Staff satisfaction survey done every month of
May and November of the year.
4 meetings and 2 staff development

activities attended, adequately informed
3. Meetings and staff development and updated per grading period.
Nursing service staff schedule finalized

and posted based on standard staffing
4. Finalization of Nursing Service Staff
pattern of DOH done every 12th and
Schedule
27th day of the month.
BAIS DISTRICT HOSPITAL
Bais City
NURSING SERVICE STAFF PERFORMANCE CHECKLIST

(LAUNDRY WORKER)
Name of Nursing : ___________________________________________

Position : ___________________________________________________
Month : ____________________________________________________
DUTIES and RESPONSIBILITIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1. Collects soiled linens, bedsheets, pillow

covers, rubber sheets from wards and
treatment areas two times a day.
2. Washes linens, bedsheets, pillow covers

and rubber sheets, etc. two times daily from
wards and treatment areas.
3. Dries, irons, folds laundry items daily.
4. Endorses cleaned and laundered items to

nursing attendant in the Nurses' Station.
Supervisor's Signature
LEGEND : NA - Not Applicable PREPARED BY:

√ - Done
X - Not Done
NOTED BY: APPROVED BY:

Performance (OPCR) (IPCR)

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INDIVIDUAL PERFORMANCE COMMITMENT AND REVIEW (IPCR)

APPROVED BY: Signature of Head of Office

Rater comments and recommendations for Development Purposes or Rewards/Promotion

The above rating has been discussed with Supervisor

Final Rating by Office Head:

APPROVED BY: Signature of Head of Office

MAJOR FINAL OUTPUT SUCCESS INDICATOR ALLOTED DIVISIONS ACTUAL RATING

7. Processing of PhilHealth and 100% of PhilHealth and PHINO claims

8. Repairs of Hospital Buildings 80% of repaired hospital building and

100% of individual Performance Commitment

100% of adm. service staff DTR's prepared and

100% of adm. service staff wore the prescribed

10 availble adm. service staff on duty

Position: Position: Position: Position: Position:

3. Report of Collections and Deposits 100% of collections and deposits accurately

4. Updating of Employees Personnel 100% of employees personnel records updated

80% of end user's request of goods and services

6. Maintenance of Medical Records 100% medical records completely maintained.

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

2. Preparation and submission of 100% of adm. service staff DTRs prepared

10 available adm. service staff on duty

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

MELINDE T. SINGCO QUINTIN C. BASCOS,MD

THELMA A. GARGANTIEL QUINTIN C. BASCOS, MD

100% effectivley participated in the eligibility

100% reffered patients to other welfare

2. Preparation and submission of 100% of adm. service staff DTRs prepared

10 available adm. service staff on duty

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

THELMA A. GARGANTIEL QUINTIN C. BASCOS, MD

100% protected and safeguared effectively life

100% cooperated hospital personnel in their

100% maintained peace and order effectively

2. Preparation and submission of 100% of adm. service staff DTRs prepared

10 available adm. service staff on duty

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

THELMA A. GARGANTIEL QUINTIN C. BASCOS, MD

100% of monthly laboratory reports prepared

100% patients laboratory examinations and

2. Preparation and submission of 100% of adm. service staff DTRs prepared

10 available adm. service staff on duty

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

GUILLERMO R. ESONA, JR QUINTIN C. BASCOS,MD

GUILLERMO R. ESONA, JR,

THELMA A. GARGANTIEL QUINTIN C. BASCOS, MD

100% repaired clogged comfort rooms and

100% repaired leaking ceiling and glutter of

2. Preparation and submission of 100% of adm. service staff DTRs prepared

10 available adm. service staff on duty

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

RONALD M. ALVARICO, DDM QUINTIN C. BASCOS,MD

RONALD M. ALVARICO, DDM

QUINTIN C. BASCOS, MD QUINTIN C. BASCOS, MD

100% performed tooth extraction effectively

2. Preparation and submission of 100% of adm. service staff DTRs prepared

10 available adm. service staff on duty

SUMMARY OF RATING TOTAL Final Numerical Rating Final Adjectival Rating

NEDIE AGADER QUINTIN C. BASCOS,MD

THELMA A. GARGANTIEL QUINTIN C. BASCOS, MD

100% of used food trays collected completely

100% maintained cleanliness and washed food

2. Preparation and submission of 100% of adm. service staff DTRs prepared