Philippine Malaria Information System (PhilMIS)

F4a

Hospital Out-Patient Monthly Malaria Report Form (HOMMRF)

MONTH AND YEAR

NAME OF FACILITY
PROVINCE
MUNICIPALITY
BARANGAY
DATE SUBMITTED
SUBMITTED TO

NAME OF PATIENT

REPORT NO.
(To be filled-up by Data Encoder)

SLIDE/RDT
NO.

RESULT

ICD 10

REMARK(S)

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
NO. OF SLIDES EXAMINED :
NO. OF RDT DONE :
NO. OF POSITIVES:

NO. OF PATIENT TESTED

NEGATIVE FOR MALARIA
WITHIN 24 HOURS

NO. OF CLINICAL DIAGNOSIS:

PREPARED BY:
DESIGNATION:
RECEIVED IN THE RHU BY :

REVIEWED IN THE RHU BY:

POSITION:
DATE RECEIVED:
RECEIVED IN THE PHO BY: (IF APPLICABLE)
POSITION:
DATE REVIEWED:

REVIEWED IN THE PHO BY: (IF APPLICABLE)