Philippine Malaria Information System (PhilMIS)

F6

Mosquito Net Distribution Form (MNDF)

PROVINCE

NAME OF FACILITY

MUNICIPALITY

DATE OF DISTRIBUTION

BARANGAY

MONTH

SITIO/PUROK
SOURCE OF NETS

GF

DOH

CHD

LGU

OTHERS

FAMILY HEAD
(Last name, First name, M.I.)

IP GROUP

NUMBER OF HH
MEMBERS

NUMBER OF
EXISTING LLIN

MOBILE

TYPE OF NETS

LLIN

NUMBER OF NEW NET(S) GIVEN

D
F
XL
Total

YEAR

DAY

TYPE OF ACTIVITY

PREGNANCY PACKAGE

REGULAR

REPLACEMENT

CONVENTIONAL NET
NUMBER OF OCCUPANTS
COVERED BY LLIN

REMARKS/ SIGNATURE/ THUMB MARK OF THE

RECIPIENT

10

TOTAL
S - Single

D - Double

F - Family

XL - Extra Large

PREPARED BY:

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RECEIVED IN THE RHU BY:

POSITION:

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POSITION:
DATE RECEIVED:

DATE PREPARED: _____________________________________

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REVIEWED IN THE RHU BY:

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RECEIVED IN THE PHO BY: (IF APPLICABLE)

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POSITION:

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POSITION:

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DATE REVIEWED:

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DATE RECEIVED:

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