Annex A LGU FORM 2.

LGU CIVILWORKS REQUIREMENTS FOR HEALTH FACILITIES, 2015 Name of Province: Ilocos Sur
Instruction : 1. The LGU Province or Chartered City )with Province-Wide or City-Wide investment Plan for Health (P/CIPH) and Annual Operations Plan (AOP) for the implementation of Kalusugang Pangkalahatan shall fill-up this form to consolidate their request for CIVIL WORKS that shall be funded by the DOH for Local Government Units or LGUs health facilities from Barangay Health Stations, Rural Health Units, Hospitals and the Provincial Health Office. 2. The LGU may attach supporting documents such as photographs of facilities in need of repair, project proposal, floor plans, program of work and resolutions among others. Make Separate sheets for the different health programs needing commodity allocation. 3. The request should be present in the P/CIPH or AOP. 4.The bottom of the page shall be signed by the Provincial of City Health officer and the Governor or City Mayor.
Status of Implementation of previous assistance (Please Tick as many as appropriate) Total Previous assistance Facility is Received by the Funds Fully Functional facility (PHP) Utilized and Utilized Facility PhilHealth Accreditation Primary Care Benefit NEWBORNSCREENING ACCREDITED HOSPITAL

Name of Municipalities and Cities where the facility shall be constructed (to be alphabetically arranged per dictrict)

Address of the Health Facility

Short description of the civil works requested

Total Cost Needed (PHP)

Short Description of Previous Amount of previous assistance from FUNDING IN 2014 assistance for civilworks in DOH and Other Partners (If none, pls indicate NA) the facility (Describe Comprehensively & specify if old, new, rehabilitation, LGU and DOH repair, upgrade, painting etc) 2011 2012 2013 other Assisted sources

DOTS

MCP

District: Second Alilem (GIDA) Construction of BemONC Construction of Daddaay and Batbato BHS Apang BHS Apaya BHS Kiat BHS Apang Apaya Kiat Construction (100 sq. m.) Construction (70 sq. m.) Construction (42 sq. m.)
2,200,000.00

n/a

n/a

25,000,000.00

/ /

n/a n/a

30% ongoing
to start this February

1,500,000.00

924,000.00

Municipal/City Health Officer

Municipal/City Mayor

LGU FORM 3.A LGU EQUIPMENT REQUIREMENT FOR HEALTH FACILITIES, 2015 Name of Healthcare Facility Location: Alilem, Ilocos Sur

Instruction : 1. The LGU (Province or Chartered City) with Province-Wide or City-Wide investment Plan for Health (P/CIPH) and Annual Operations Plan (AOP) for the implementation of Kalusugang Pangkalahatan shall fill-up this form to consolidate their request for EQUIPMENT/FIXTURE that shall be funded by the DOH. 2. The LGU m provide supporting documents such as pictures of old non-functional equipment, facilities lacking equipments, specifications, canvass and resolutions for request among o The request should be present in the P/CIPH or AOP. 4.The bottom of the page shall be signed by the Provincial of City Health officer and the Governor or City Mayor.

Number of Units Name of Equipment /Fixture (alphabetically arranged) Brief Description / Specifications of Equipment / Fixture Unit Cost Existing as of December 2013 Provisions in 2014 Requests in 2015

Package for Basic Equipment for BHS Birthing Facility Batbato Daddaay Apaya Apang Kiat TOTAL

Municipal/City Health Officer

Municipal/City Mayor

Annex A

U FORM 3.A MENT FOR HEALTH FACILITIES, 2015

de investment Plan for Health (P/CIPH) and Annual Operations Plan (AOP) for the their request for EQUIPMENT/FIXTURE that shall be funded by the DOH. 2. The LGU may cilities lacking equipments, specifications, canvass and resolutions for request among others. 3. l be signed by the Provincial of City Health officer and the Governor or City Mayor.

Total Cost

Municipal/City Mayor