Philippine Malaria Information System (PhilMIS)

Pregnancy Package Distribution Summary Form

F13
Month and Year
Name of Facility
Province
Entry
No.

Source of Nets
Date of
Distribution

Municipality

Barangay

Purok/Sitio

No. of
Pregnant
Women

GF

DOH

CHD

LGU

OTHERS

NO. OF ITEMS
No. of IP

LLIN
Distributed

Ferrous
Sulfate

Albendazole

Mother and
Child Booklet

IEC Materials

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

TOTAL
Prepared by:

Received in the
RHU by:

Reviewed in the RHU by:

Received in the
PHO by:

Position:

Position:

Position:

Position:

Date Prepared:

Date Received:

Date Reviewed:

Date Received:

Remarks