Republic of the Philippines

Department of Interior and Local Government Unit

BUREAU OF JAIL MANGEMENT AND PENOLOGY
Regional Office VI - Health Service Office
3rd Floor, Angeles Arcade Building, Mabini Street, Iloilo City
Tel No. (033) 503-4018

Quarterly Report on All TB Cases

Name of CHD: Patient Registered during the ______ Quarter
of the year ____

Name of PHO/CHO: Date Submitted:

Name of Jail Facility:

Name & Designation

Average Jail Population: __________ Ave. Jail Commit: _________ Ave. Jail Release: _________
Treatment started w/in 24
Presumptive TB Cases TB Case Detected Sputum Examination Referrals
hours

(+)
ent red who

DR-
(SR)

ve ID

ys e
S)

DSSM ine th e
ru
M

s
ear
ce (S
Iden umtive

examumptiv
)

w/n dx relea
Scre tifed /

nt
DSS

t (EX

e
trea going
der

Age
try

rral

TB umptiv
Surv ptoms

case um sm

(+/-) Tested
ti

tme
d

und of refe

SR

SR
EN

EN
5 da
ump
EX

EX
e ne

SS

SS
at En

eilan

Group
Gen

Refe

i
at Ex
Pres

On-
Pres
erw

Lab
Pres
Sym

Pres
Sput
s

HIV
Self
No.

M
15-24
F
M
25-34
F
M
35-44
F
M
45-54
F
M
55-64
F
65 and M
ABOVE F
M 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL

“Changing Lives, Building a Safer Nation.”

TOTAL
F 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
GRAND TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

“Changing Lives, Building a Safer Nation.”