DOTS Facility _________________________________________________ Quarterly Report on NTP Laboratory Activities (Source of Data NTP Laboratory Registers) ___________________ Quarter,

, ________________ Name of DOTS Facility: ______________________________ TB Symptomatics/patients:___________________ Total population of catchment area:________________ Examined during ___________qtr of ____________ Date Reported: ________________________________ Prepared by: _________________________________________ Designation: ___________________________________ Casefinding: Laboratory Activities 1. No. of TB Symptomatics examined 2. No. of TB Symptomatics with 3 sputum specimens 3. No. of TB Symptomatics diagnosed as Smear-positive with 2 or more positive results: (including the number of doubtful cases in the 1st collection with at least one positive result in the 2nd collection set) 4. Positivity Rate* 5. No. of TB Symptomatics with Doubtful result: Treatment Follow-Up 6. No. of follow-up examination done 7. No. of smear-positive cases among the follow-up examinations Male Female TOTAL

*Positivity rate is an important indicator of microscopy performance. POSITIVITY RATE = Total no. of sputum smear positive cases Total no. of TB symptomatics examined X 100

Reported By: ________________________________________________ Med. Tech. / Microscopist (Signature over Printed Name)

NAME OF DOTS Facility: ______________________________________________________________ QUARTERLY TBDC ACCOMPLISHMENT REPORT FORM ____________________ quarter, 20___________ Name of Region: CHD 6 Name of Province: Negros Occidental Name of CHO/RHU: La Carlota City Health Office Date Submitted: ________________________ Data for the _____________ Quarter of, 20 _______ Prepared by: Jenena D. Baculna______ 1. Total no. of (smear ( - ), x-ray positive) TB symptomatic referred to as TBDC 1.1 Classification of referred TB symptomatics: Male Female Total TB New: TB Re-treatment: Total:

TBDC Diagnosis
2. Total number of active TB causes diagnosed by TBDC 2.1 Classification of active TB cases diagnosed by TBDC TB New: TB Re-treatment: Total: 3. Total number of inactive TB patients 4. Total number of patients diagnosed as Other lung disease 5. Total number of patients recommended by the TBDC for anti-TB treatment this quarter (same total as #2) 6. Total number of patients evaluated by TBDC for this quarter (total of #s 3, 4 & 5
NOTED: ERWINA FRANCES B. JALANDONI M.D., MPH. City Govt. Dept. Head I/CHO II

Male Female Total

Name of DOTS Facility : LA CARLOTA CITY MAIN HEALTH CENTER ________ Quarter of 20_____

NTP Quarterly Report on the Treatment Outcome of Pulmonary TB Cases

( Source of Data TB Register ) Name of Region: Province: Name of RHU / CHO: Prepared By: Designation:
Total Number of Pulmonary TB Cases

CHD 6 Negros Occidental LA CARLOTA CITY HEALTH OFFICE JENENA D. BACULNA Public Health Nurse II
Type Cured Com- Died pleted Treatment

Patients registered during the __________ qtr of 20 __________ Date Reported: _____________________
Failed De- Trans- Total faulted ferred Number Out Evaluated

(Copy of the total number reported in the Case Finding Report during the same quarter)

F
1. New Cases
1.1 Smear (+) 1.2 Smear (-)

M F M

F M F M

F M

F M

2. Re-treatment
2.1 Relapse 2.2 Treatment Failure 2.3 Return After Default

GRAND TOTAL
* As those, ________________ ( ) were excluded from evaluation of chemotherapy for the following reasons:

_________________________ Trans-In _________________________ Extra Pulmonary _________________________ Other NOTED: ERWINA FRANCES B. JALANDONI M.D., MPH. City Govt. Dept. Head I/CHO II

Name of DOTS Facility: LA CARLOTA CITY MAIN HEALTH CENTER

QUARTERLY REPORT ON ALL TB CASES

(Source of Data TB Register) Name of Region: CHD 6 TB patients registered during _______ qtr of 20_______ Province: Negros Occidental Name of CHO/RHU: La Carlota City Health Office Date Submitted: ________________________ Prepared by: JENENA D. BACULNA
CASEFINDING A. Pulmonary Tuberculosis 1. Smear-Positive cases 1.1 New AgeGroup (Years) 0-9 10-14 15-24 25-34 35-44 45-54 55-64 65 & above

Designation: PHN II_____________________

Public Male Female Private Male Female TOTAL

Sub-total 1.2 Relapse 1.3 Treatment Failure 1.4 Return After Default 1.5 Other-positive 1.6 Trans-In 2. Smear-Negative cases 2.1 New Cat I Cat III 2.2 Other negative 2.3 Trans-In 3. Extra-pulmonary tuberculosis Sub-total TOTAL
NOTED: ERWINA FRANCES B. JALANDONI M.D., MPH. City Govt. Dept. Head I/CHO II
Total Number of Patients under the following Categories: CAT I CAT II CAT III