Republic of the Philippines

Department of Health
Regional Office XII
Cotabato City

EXIT CLEARANCE

This is to certify that _________________________________________________________,

NDP/RHMPP/UHCI/PHA/MEDTECT/DENTIST/PHYSICIAN AUGMENTATION assigned in this office for the period of
_______________ to _________________ has been cleared from his/her duties and responsibilities and has no unsettled
accountabilities for the following obligations:

( ) Financial Obligation

( ) Supplies/Equipment’s

( ) Administrative Obligations

( ) Pertinent report/records of barangay assignment submitted

( ) Complete monthly/annual reports turned-over

( ) BHS ________________________________ _________________________________

VERIFIED SIGNATURE BY MIDWIFE VERIFIED SIGNATURE BY MIDWIFE

( ) RHU ___________________________
VERIFIED SIGNATURE BY PHN

( ) Others ________________________________

Signed by:

__________________________ ____________________________
NDP TEAM LEADER PHN PRECEPTOR

Date: _________________ Date: _________________

__________________________
MHO

Date: _________________

ENGR. EUSEBIO D. ESPINOSA, JR. MERCEDES L. MANANSALA, MD, MPH

DMO Provincial DOH Officer, SK Province

Date: ________________ Date: _________________