ACCOMPLISHMENT REPORT FOR AUGUST 2020

NAME: SURNAME, FIRST NAME, MIDDLE INITIAL

CADRE: NURSE/MIDWIFE
MUNICIPALITY: NAME OF MUNICIPALITY
ASSIGNED BARANGAY/S: NAME OF ASSIGNED BARANGAYS/S

1. FIELD DUTY YES/NO DATE/S: MM/DD/YYYY

1.01 Referral to Primary Care Provider YES/NO Mode of Verification

No. of referred patients: number Document/s presented:
No. of referred patients who went to a health provider: number Name of MOV document
Percentage of referred patients who went to a health provider: #VALUE! Validated/ checked by:
Choose one (1) HRH to
check your MOV

1.02. National Immunization Program YES/NO Mode of Verification

No. of children vaccinated with: Document/s presented:
BCG number MCV number Name of MOV document
HepB number
OPV number Rotavirus number
PENTA number PCV number Validated/checked by:
IPV number MMR number Choose one (1) HRH to
No. of adolescents vaccinated with HPV: number check your MOV
No. of senior citizens vaccinated with: PCV number
Flu Vaccine number

1.03 Adverse Event Following Immunization YES/NO Mode of Verification

Observation and action given: Document/s presented:
Provide a narrative on the AEFI encountered. Name of MOV document
Validated/ checked by:
Choose one (1) HRH to
check your MOV

1.04 Family Planning YES/NO Mode of Verification

No. of Current Users for: Document/s presented:
NFP number Injectable number Name of MOV document
Vasectomy number POP number
BTL number COC number
IUD number Implant number
No. of New Acceptors for: Validated/ checked by:

NFP number Injectable number Choose one (1) HRH to

Vasectomy number POP number check your MOV
BTL number COC number
IUD number Implant number

1.05 Prenatal Care YES/NO Mode of Verification

No. of pregnants provided with prenatal care: number Document/s presented:
No. of pregnants given TT vaccine: number Name of MOV document
No. of pregnants given iron (folic acid): number Validated/ checked by:
Choose one (1) HRH to
check your MOV

1.06 Postpartum Care Mode of Verification

No. of PP mothers eligible for PP care: number Document/s presented:
No. of PP mothers visisted within seven (7) days: number Name of MOV document
No. of PP mothers given iron: number Validated/ checked by:
No. of PP mothers given vitamin A: number Choose one (1) HRH to
check your MOV
1.07 Nutrition Services YES/NO Mode of Verification
Nos. of children given Vitamin A: number Document/s presented:
Nos. of mothers monitored for EBF: number Name of MOV document
Nos. of NBS facilitated: number
Nos. of infants and children given iron: number Validated/ checked by:
Nos. of infants and children given MNP: number Choose one (1) HRH to
Nos. of children dewormed: number check your MOV

1.08 Communicable Disease YES/NO Mode of Verification

Nos. of referred presumptive cases of TB: number Document/s presented:
Name of MOV document
Nos. of positive cases from the presumptive TB cases: number Validated/ checked by:
Choose one (1) HRH to
check your MOV

1.09 Non-Communicable Disease YES/NO Mode of Verification

Nos. of patients provided COMPAQ medicines: number Document/s presented:
Name of MOV document
Validated/ checked by:
Choose one (1) HRH to
check your MOV

1.10 Other Services Provided Any health services that you have provided in the community other
than above mentioned.

1.11 Attendance to Barangay Sessions/Meetings YES/NO Mode of Verification

Dates of Barangay Dates Document/s presented:
sessions/meetings Name of MOV document
attended:
Validated/ checked by:
Choose one (1) HRH to
check your MOV
1.12 Health Education and Trainings YES/NO Mode of Verification
Health education and Subject of your health education and training and the feedback Document/s presented:
training provided to the of your recipients. Name of MOV document
community and the
Validated/ checked by:
feedback.
Choose one (1) HRH to
check your MOV

2. RHU DUTY YES/NO DATE/S: Dates

Assisted in the following:
1. CONSULTATIONS (triage, dispending of medicines, among others)? YES/NO
2. BIRTHING FACILITY? YES/NO
3. PROCEDURES (minor surgery and medico-legal, among others)? YES/NO
4. VACCINATIONS (NIP, ABC, SC)? YES/NO
5. ISSUANCE OF MEDICAL CERTIFICATE CLEARANCE, TRAVEL PASS AND HEALTH DECLARATION? YES/NO
6. OTHER SERVICES Services not mentioned, kindly indicate here.

3. QUARANTINE/ YES/NO DATE/S: Dates

ISOLATION FACILITY
DUTY:
Recommendations: Recommendations to improve the your working condition and provision of health services
related on this pandemic.

4. Field Health Data YES/NO

Names of reports submitted Name of reports that you have submitted for your field health data.
for field health data:

5. Performed Contact Tracing YES/NO

6. Other Tasks Performed: Any other tasks that you have performed this month not mentioned above.

Prepared by:
{{Name (SURNAME, FIRST NAME, MIDDLE INITIAL)}}
{{Cadre:}},{{Indicate your Municipality.}}

Approved by:
{{Choose the name of your Municipal Health Officer.}} Kristine R. Galamgam, RN, MPH
Municipal Health Officer, {{Indicate your Municipality.}} Development Management Officer IV