USAPANG Kuntento na Pwede Pa Bagong Maginoo

Attendance Record TOTAL # of participants: _______

Source of participants (Check primary): TOTAL # given one-on-one counseling: _______
Date and Time: _______________________________________________________ BHW Masterlist CHSR TOTAL # of Current Users: _______
Venue/Facility: _______________________________________________________ POPCOM Database FP/ANC-EPI TOTAL # of New Acceptors: _______
Municipality/City and Province: _______________________________________________________ FDS TOTAL # of Other Acceptors: _______
Facilitators/HSPs: _______________________________________________________ OTHER:_________________________________ TOTAL # Referred Clients: _______

Sasagutan ng Client Sasagutan ng HSP

Gusto mo pang Nakagamit Gumagamit

magka-anak? ka ba noon ka ba ngayon Nabigyan
Nabigyan ng FP
ng FP ng FP ng one- Ni-refer sa ibang
PANGALAN method? method? method (Isulat ang
KASARIAN on-one facility? 
(Participant/Mag-asawa/ EDAD ADDRESS PHONE  Kung  Kung LAGDA method, ilagay kung
Mag-partner) (M or F) Hindi Hindi hindi. hindi. counsel-
NA o OA,)
na muna Kung oo, Kung oo, ing ? Isulat kung saan.
Kung hindi, bakit?
  anong anong 
method? method?

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