Form 3: other Services Coverage

Month:_________ year: 2016

Region: VII Province/City: BOHOL
Iron Supplementation Dental Oral Health Salt Testing
No. of children No. of No. of 13 71 months
Pregnant lactating (Total pop x 13.5% x Service Target 20%) Household Market
Given
Women Women
Drops Syrups Given tablets Given tablets Eligible Target No. Examined % No. of Sample No. of positive % No. of Sample No. of positive %

Other Activities:
TARGET NO. %
*No. of mothers given premarital counselling
*No. Mothers given prenatal counselling
*No. of pregnant mothers consulted in Health Centre
*No. of mothers given birth spacing Counselling
*No. of mother exclusively Breastfeeding
*No. of mothers counselled on complementary feeding
*No. of mothers counselled on Detrimental Effects on Tobacco Smoking
*No. of mothers given IEC materials
*No. of Children weighed
*No. of children taken height
*No. of children consulted of safety tips on child injury

Prepared by: Noted:

Name and Designation Name and Designation
 Form 4: Inventory
Month: Year:
Region: Province/City: Municipality:

Name of Vitamin A Capsule Micronutrient Powder (in box) Deworming Drugs (in bottles)
catchment Population 100,000 IU (in bottles) 200,000 IU (in bottles)
areas
Allocation Delivered Balance Allocation Delivered Balance Allocation Delivered Balance Allocation Delivered Balance

Prepared by: Noted by:

Name and Designation Name and Designation

Notes:
*Allocation means received from the regional/province/city
*Delivered means distributed to the catchment area
*Balance means the remaining available at the health facility