ATTENDANCE INFORMATION SHEET

USAPAN SERIES FOR FAMILY PLANNING __ Kuntento Na __ Pwede Na __ Bagong Maginoo

Total Number of participants
Batch No. _______________ Total no. of clients given one-on-one
Province: _______________ Municipality:___________ Facility: ________________ counselling
Date and Time: _________________ Current FP user
Health Service Providers involved: _____________________________________ Total no. of New Acceptors
_________________________________________________________________ Total no. of Other Acceptors
Total no. of Referred Clients

(Sagutin ng Cllient) (Sasagutin ng Health Service Provider)

Nakatangga
Kasarian p ng FP
method
M F Nakagamit Gumagamit ka
(Kung Ni-refer sa
ka bang FP ba ng FP
tumanggap, ibang facility
Gusto mo pa method method Nakatangga
No Pangalan (Participant/Mag- Ilan ang isulat ang (x/√) ilagay
Edad Tirahan (Address) bang magka- noon? ngayon? Lagda p ng one-
. asawa/Magpartner) anak mo? method at ang
anak? (Y/N) Kung OO, Kung OO, on-one
ilagay kung pangalan ng
anong anong
NA o OA. facility
method? method?
Kung hindi,
isulat ang
dahilan
1