INDIVIDUAL PERFORMANCE COMMITMENT A

I, HAZIEL S. ALFANTA, R.N., of the Regional Office VI - DOH assigned at the Municipality of Culasi, Province of Antique, commit t
the indicated measures for the period February to June, 2017.

HAZIEL S. ALFANTA, R.N.

Approved By:
IRENE D. SOMBILON, R.N., M.P.H.
Name of Supervisor

SUCCESS INDICATOR
Output
(Targets + Measure) Q

80% of 5 Barangays with CPR of 65% or 3.00- 80% of 5 Barangays were assisted
more assisted in providing Family in providing comprehensive and
Planning Services as scheduled accurate Family Planning Services with
proper counseling and administration of
commodities.

80% of 5 Barangays with FIC of 95% or 4.00- 100% of 5 Barangays with FIC of
more assisted in providing 95% or more were provided appropriate
immunization services once a month. immunization services.

80% of 5 Barangays with MMR of 80% 4.00- 100% of 5 Barangays with MMR of
or more assisted in providing 80% or more were provided appropriate
immunization services once a month. immunization services.

80% of 5 Barangays with ANC 5 of 90% 4.00- 100% of 5 Barangays with ANC of
or more assisted in providing pre-natal 90% or more were assisted in providing
Service Provision visit once a month. quality pre-natal services with minimal
supervison.

80% of 5 Barangays with 2 PPs of 90% or 3.00- 80% of 5 Barangays with 2 PP

more assisted in providing post-natal visits of 90% or more were assisted in
services once a month. providing quality post-natal services
with minimal supervison.
 80% of 5 Barangays with 100% of
pregnant women with Birth and
Emergency Plans provided during pre-
natal visit as scheduled.
80% of 5 Barangays with 85% referral
for NBS.
80% of 5 barangays with defaulters
among NHTS and Non-NHTS with SWRA
of unmet needs for Modern Family
Planning are counselled through
USAPAN and has been provided with FP
commodities.
80% of 5 barangays among NHTS and
Non-NHTS with 15% of defaulter for
ANC provided with pre-natal services.
80% of 5 barangays assigned among
NHTS and Non-NHTS with 15% of
teenage mothers defaulter for ANC
Defaulter Tracking provided with pre-natal services.
80% of 5 barangays assigned among 4.00- 100% of 5 Barangays with 20% of
NHTS and Non-NHTS with 20% of 0-2yo 0-2yo defaulter for immunization were
defaulter for immunization provided given with appropriate vaccine.
with appropriate vaccine monthly.
80% of 5 barangays assigned among
NHTS and Non-NHTS with 10% of
Severely Acute Malnourish (SAM)
children (<5yo) provided with
treatment and management monthly.
95% of 5 barangays assigned with
validated M1 report submitted every
15th day of the month.
Reports
4.00- 100% of 5 Barangays have 100%
Birth and Emergency Plans.
3.00- 80% of 5 Barangays with 85%
referral for NBS.
3.00- 80% of 5 Barangays with
defaulters among NHTS and Non-NHTS
with SWRA with unmet needs for
Modern Family Planning are counselled
through USAPAN and has been provided
with FP commodities.
4.00- 100% of 5 Barangays with 15% of
defaulter for ANC were identified and
provided comprehensive quality pre-
natal services
4.00- 100% of 5 Barangays with 15% of
teenage mothers defaulter for ANC
were provided comprehensive quality
pre-natal services.
4.00- 100% of 5 Barangays with 10% of
Severely Acute Malnourish (SAM)
children (<5yo) were appropriately
provided with treatment and
management.
4.00- 100% of 5 Barangays assigned has
a complete and validated M1 Reports
with minimal error and needs minimal
revision.
 95% of 5 barangays assigned with
validated NSMP submitted every 15th
day of the month.
Reports
4.00- 100% of 5 Barangays assigned has
a complete and validated NSMP
Reports with minimal error and needs
minimal revision.

95% of 5 barangays assigned with 4.00- 100% of 5 Barangays assigned has

validated EPI submitted every 15th day a complete and validated EPI Reports
of the month. with minimal error and needs minimal
revision.

5 Accurate and updated monthly 3.00- 5 Completed and updated

inventory review of 100% of MNCHN
logistics and supplies including Updated
Vaccine/ Syringes Stock Card, FP
Logistics Inventory Card/ Logbook, and
Updated Logbooks on Vit. A, Ferrous
Sulfate, ECCD Card/ Mother and Child
Book and inventory review of FP
Inventory of Logistics in Barangays assigned
Supplies submitted every end of the month.
accurate monthly inventory review of
100% of MNCHN logistics and supplies
in 4 Barangays including Updated
Vaccine/ Syringes Stock Card, FP
Logistics Inventory Card/ Logbook, and
Updated Logbooks on Vit. A, Ferrous
Sulfate, ECCD Card/ Mother and Child
Book and inventory review of FP
Logistics accomplished without errors;
well organized and presented.

80% of 5 barangays assigned with 4.00- 100% of 5 Barangays has an

Inventory of Personnel Skills (Training Inventory of Personnel Skills (Training
Inventory on MNCHN Programs) done Inventory on MNCHN Programs).
Skills Inventory as scheduled

80% of target Clients for MNCHN 4.00- 95% of 5 Barangays with targets
Services among NHTS - PR and non- for MNCHN Services among NHTS - PR
NHTS: List of SWRA with Unmet Needs, and non-NHTS received appropriate
Pregnant women enlisted in their first services.
trimester, All pregnant women including
teenage pregnancy and their outcomes,
List of FBD, SBA and home deliveries,
Clients for NBS, Missed Children(MMR/
Masterlist MCV2) and Children who are stunted
and wasted of 5 Barangays assigned
every end of the month.
 5 Meetings with 1 meeting per month
for MNCHN Data Validation, Analysis
and Utilization conducted in 100% of
Barangays assigned every end of the
month
Attendance to LGU
Meetings
4.00- Attended LGU Meetings for
MNCHN Data Validation, Analysis and
Utilization, and other program concerns
conducted with effective and efficient
participation, deliberations, updates
and different problems and issues have
been tackled and solved in 100% of 5
Barangays assigned.

1 USAPAN Session per catchment 3.00- Effectively conducted USAPAN

barangay (Usapang Buntis, Pwede Pa Session (Usapang Buntis, Pwede Pa and
and Tama na) in 80% of 5 Barangays Tama na) in 80% of 5 Barangays
USAPAN Session once a month assigned.

80% of target clients weighed and given 4.00- 100% of Target clients weighed
Vitamin A, Micronutreint Supplements and given Vitamin A and appropriate
Garantisadong on scheduled month Micronutreint Supplements.
Pambata

80% of 5 barangays assigned with target 4.00- 90% of target Senior Citizens
Senior Citizens screened and immunized screened and immunized against
Senior Citizens as scheduled Pneumonia.
Immunization

80% of 5 barangays implemented 4.00- 100% of 5 Barangays implemented

PhilPen with properly filled up Health PhilPen with filled up Health Risk
PhilPen Health Risk Assessment Form every month Assessment Form.
Risk Assessment

1 Advocacy information dissemination 3.00- Disseminated 3 Advocacy

through health education on Maternal, Information in 4 Barangays within a
Neonatal Child Health and Nutrition in 5 month.
Health Advocacies Barangays once a month.

Delivered prompt and quality RHU 4.00- RHU Health Services

Health Services to 100% of actual clients (Consultation, MNHCHN services, DOTS)
served within 8am - 5pm schedule done to 100% of actual clients served
Health Service in within 8am - 5pm schedule.
the RHU provided

Referred 80% seen and examined 4.00- Referral of 100% high risk clients
pregnant women and children below 5 with danger signs and immediated
years old within 24 hours upon needs given approriate interventions.
Referral Done detection

Report from 8am - 5pm as scheduled 4.00- 100% of tasks done in station
Attendance in working in stations assigned assigned within eight hours.
stations as
scheduled
 Does 80% of priority tasks for the day as 4.00- 100% of priority task assigned
assigned/ identified without delay and done within the day.
Deliverables correctly based on protocols and
Performed procedures

Reflected correct and logbook-based 4.00- Daily time records of 100% of

entries of 100% of working days within working days accomplished within an
the month concerned hour and submitted 2-3 days prior the
Daily Time Records due date.

RATING

Total Overall Rating

Final Average Rating

Adjectival Rating

Comments and Recommendation for Development Purposes

Discussed With: Assessed by:

I certify and discussed my assessment of the performance

IRENE D. SOMBILON, R.N., M.P.H.

HAZIEL S. ALFANTA, R.N.
Employee Supervisor
Legend: 1- Quality 2 -Efficiency 3 - Timeliness 4 - Average
 DOH - SPMS Form 3
COMMITMENT AND REVIEW (IPCR)

f Antique, commit to deliver and agree to be rated on the attainment of the following targets in accordance with

Date: June 18, 2017

Date

5 – Outstanding
4 – Very Satisfactory
3 – Satisfactory
2 - Unsatisfactory
1 - Poor

A Remarks
E T
(4)
4.00- 5 Barangays educated and assisted 4.00- Services provided as scheduled in
in providing Family Planning Services. 5 barangays within 5 minutes upon
arrival.

3.67

4.00- 5 Barangays were efficiently 4.00- Services provided twice a month

educated and assisted in providing in 5 barangays assigned.
appropriate immunization services.
4.00

4.00- 5 Barangays were educated and 4.00- Services provided twice a month
assisted in providing immunization in 5 barangays assigned.
services.
4.00

4.00- 5 Barangays were educated, 4.00- Services provided in 5 barangays

encouraged for, assisted/ providided assigned two to three times a month.
pre-natal services.
4.00

4.00- 5 Barangays were educated, 4.00- Services provided in 5 barangays

assisted, provided post-natal services. assigned 1 day after giving birth.

3.67
4.00- 5 Barangays were provided and 4- Services provided as often, at least
effectively emphasized information and twice a month, in 5 barangays assigned.
importance about birth and emergency
plans during pre-natal visits. 4.00

4.00- 5 Barangays' NBS referred 4.00- Services provided during first visit
efficiently, promtly, and properly. in 5 barangays assigned.
3.67

4.00- 5 barangays with defaulters for 4.00- Defaulters tracked on identified 5

Modern Family Planning are effectively barangays assigned given services
and properly counselled and within 5 minutes upon arrival.
encouraged about the use of FP
methods through USAPAN and referred
for provision of FP commodities not 3.67
more than 1 week upon identification.

4.00- 5 barangays with defaulter for 4-Defaulters tracked identified on 5

ANC are identified and provided barangays assigned done twice a month
comprehensive quality pre-natal
services within 5 minutes upon arrival. 4.00

4.00- 5 barangays assigned among NHTS 4.00- Defaulters tracked identified on 5

and Non-NHTS with 15% of teenage barangays assigned done twice a
mothers defaulter for ANC were month.
identified and provided wih pre-natal 4.00
services not more than 1 week upon
identification. One on one counseling
and confidentiality observed.

4.00- 100% of 5 barangays assigned 4.00- Defaulters tracked identified on 5

among NHTS and Non-NHTS with 20% barangays assigned done twice a
of 0-2yo defaulter for immunization month.
were identified, tracked, assessed, and 4.00
provided EPI services not more than 1
week upon identification.

4.00- 5 barangays assigned among NHTS 4.00- SAM children tracked identified
and Non-NHTS with 10% of Severely on 5 barangays assigned done twice a
Acute Malnourish (SAM) children month.
(<5yo) were identified and
appropriately educated and provided 4.00
with treatment and management not
more than 1 week upon identification.

4.00- 5 barangays assigned with 4.00- M1 Reports submitted in the 7th

complete and validated M1 reports day of the succeeding month.
submitted every 7th day but not later
than 15th day of the succeeding month. 4.00
4.00- 4 barangays assigned with 4.00- NSMP Reports submitted in the
complete and validated NSMP reports 7th day of the succeeding month.
submitted every 7th day but not later
than 15th day of the succeeding month.
4.00

4.00- 5 barangays assigned with 4.00- EPI Reports submitted in the 7th
complete and validated EPI reports day of the succeeding month.
submitted every 7th day but not later
than 15th day of the succeeding month. 4.00

4.00- Well organized, well-presented, 4.00- Logistics Inventory submitted in

validated, accurate and updated the 10th day of the succeeding month.
MNCHN logistics and supplies and
inventory review of FP Logistics in 5
Barangays assigned within the month
concerned.

3.67

4.00- 4 barangays/1 BHS assigned has 4.00- Skills Inventory Report submitted
completed, accurated, and updated 5 days prior scheduled time of passing.
Inventory of Personnel Skills (Training
Invenotory on MNCHN Programs) 4.00
accomplished 2 days before end of the
month.
4.00- Clients for MNCHN Services in 5 4.00- Masterlist updated every 2 weeks.
Barangays assigned were identified,
provided with services, monitored,
referred appropriately, and masterlisted
every 2 weeks.

4.00
4.00- Attended and participated in LGU 4.00- LGU Meetings conducted every
staff meetings. Monday or Friday each week.

4.00

4.00- Actively participated, attended, 4.00-USAPAN Session conducted once a

and conducted USAPAN Session per month.
catchment barangay (Usapang Buntis,
Pwede Pa and Tama na) in 4 Barangays. 3.67

4.00- Target clients properly and 4.00- Weighing and giving of Vit A as
accurately assessed, weighed and given well as Micronutrient Supplementation
Vitamin A and appropriate done as scheduled
Micronutreint Supplements. 4.00

4.00- Target Senior Citizens identified, 4.00- Senior Citizen immunized as

thouroughly screened and correctly scheduled.
immunized against Pneumonia. Given 4.00
also with health education.

4.00- 5 barangays facilitated and 4.00- PhilPen Risk Assessment Form

implemented PhilPen with complete, done weekly.
updated and properly filled up Health 4.00
Risk Assessment Form.

4.00- Conducted and implemented 4.00- Advocacy information

quality and efficient advocacy dissemination done twice a month.
information dissemination through
health education on Maternal, Neonatal 3.67
Child Health and Nutrition, and Family
Planning.
4.00- Facilitated, provided, and 4.00- RHU Health Services rendered
delivered prompt, quality, evidence- within duty hours.
based practices and effective RHU
Health Services (Consultation, MNHCHN 4.00
services, DOTS).

4.00- Proper and quality referral of 4.00- Referral done and services given
seen and examined high risk pregnant immediately within 5 minutes upon
women and children below 5 years old detection.
with danger signs. Appropriate services 4.00
given as needed .

4.00- Reports and logs punctualy and is 4.00- Present during duty hours with
present from 8am to 5 pm with tasks tasks done immediately as needed.
properly done. 4.00
4.00- Complied and accomplished
priority task assigned for the day with
quality, accuracy and timely based on
protocols and procedures. Minimal
supervision needed.
4.00- Task done according to urgency
within 30 minutes upon the need arises.
4.00

4.00- Practiced and reflected correct 4.00- Daily time records accomplished
and legible logbook-based entries with and submitted 2-3 days prior the due
no errors. date. 4.00

113.69

3.9203

Date Final Rating by: Date

FEMAN RENE M. AUTAJAY, M.D., M.H.A.,

P.C.H.A
Next Higher Supervisor