SAC Feedback Sample

REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF HEALTH
HEALTH PROMOTION BUREAU
Date of Review & Validation:_______________
City/ Province Provine A Region
Reproductive Health and Health Wellness Center (STI, HIV, and

AIDS Prevention, Treatment, Care, and Support Facility)
Name/Title of the Health Promotion Intervention
(Please put only one program/project/policy in this checklist.)
LEGEND
Sufficient For validation For action
Priority Area CHD Validation Feedback
PA1: Diet and Exercise
PA2: Environmental
Health
PA3: Immunization
PA4: Substance Use
PA5: Mental Health Please provide data source and parameter.
PA6: Sexual and Submitted Data and Parameter: HIV health

Reproductive Health survey, percent of individuals with HIV
Accepted Data and Parameter: HIV health
survey, percent of individuals with HIV
PA7: Violence and Injury Submitted Data and Parameter: Domestic

Prevention abuse prevalence, # of abused children and
adolescents
Accepted Data and Parameter: None
Feedback: Link of parameter to the health
promotion intervention cannot be verified.
Please provide clearer explanation of the
problem and how the intervention
addresses it in question #1.
OVERALL SCORE: 18/20
Build Healthy Public Self Appraisal CHD Feedback

Policy Validation
Is there a local policy ⚫ Yes 〇 No Submitted MOV: Copy of Ordinance no.

(i.e., ordinance/ 0679-19 series of 2019 “Province A
resolution/EO) that Comprehensive STI, HIV, and AIDS
supports the ordinance of 2013)
implementation of the Accepted MOV: Copy of Ordinance no.
Department of Health - Health Promotion Bureau

2nd Floor, Building 18, San Lazaro Compound, Tayuman, Santa Cruz, Manila, Metro Manila, 1003, Philippines
Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
health promotion 0679-19 series of 2019 “Province A

intervention/activity? Comprehensive STI, HIV, and AIDS
ordinance of 2013)
Is the local policy still ⚫ Yes 〇 No
in effect (i.e., not
repealed by other
policies, re-issued by
current chief
executive)?
Is the local policy ⚫ Yes 〇 No

aligned with a national
law?
Does the policy have a ⚫ Yes 〇 No

background that
explains the problem/s
and the reason/s why it
should be addressed?
Does the policy ⚫ Yes 〇 No

contain the objectives
and specific outcomes
that implementers aim
to achieve?
Does the policy state ⚫ Yes 〇 No

where the
funds/resources for the
intervention/activities
will be coming from?
Does the policy ⚫ Yes 〇 No Submitted MOV: None

identify individuals or Accepted MOV: Copy of Ordinance no.
offices who will be 0679-19 series of 2019 “Province A
implementing the Comprehensive STI, HIV, and AIDS
intervention/activities ordinance of 2013), photos and other
and what their specific documentations of recent activities
roles are?
Create Supportive Self Appraisal CHD Feedback

Environments Validation
Is there a physical ⚫ Yes 〇 No Submitted MOV: Photos of outreach HIV

space/ environment testing venue, photos of HIV testing
(e.g., room, building, facility
street, walkway, Accepted MOV: Photos of outreach HIV
open/green space, testing venue, photos of HIV testing
designated space/area, facility
etc.) that supports the
implementation and
enforcement of the
intervention?

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
Are these identified ⚫ Yes 〇 No Submitted MOV: Photos of outreach HIV

spaces/environments testing venue showing wheelchair ramp
safe, secure, and free and PWD elevators
from interference and Accepted MOV: Photos of outreach HIV
obstructions when testing venue showing wheelchair ramp
conducting an and PWD elevators
intervention/activity?
Is the intervention free ⚫ Yes 〇 No Submitted MOV: Health provider

from orientation on local AIDS ordinance,
procedures/processes certificates of trainings with integrated
that could prevent SOGIE education
persons with Accepted MOV: Health provider
disabilities or persons orientation on local AIDS ordinance,
of different certificates of trainings with integrated
socioeconomic SOGIE education
class/cultural
background/educationa
l level from
participating in the
intervention?
Reorient Health Self Appraisal CHD Feedback

Services Validation
Are the human and/or ⚫ Yes 〇 No Submitted MOV: Project Procurement

financial resources Plan*
needed for the Accepted MOV: None
implementation of the Feedback: Please provide a copy of
intervention made Project Procurement Plan (PPMP) Jan-
available in the LGU? Dec 2021 as indicated in the submitted
checklist.
Are the resources 〇 Yes ⚫No To be considered achieved in KRA 1.4,

needed for the all items in the checklist should be
implementation of the sufficiently accomplished.
intervention included
in the LGU’s approved The following are acceptable MOVs for
financial plans? this item:
● Work and Financial Plan
● Project Procurement Management Plan
● Fund Utilization Reports
● Annual Investment Program/Annual
Procurement Plan
● Local Development Investment Program
● Documentation/photos of purchases
● Narrative reports
● Local Investment Plan for Health
● Proof of filled-up positions (i.e.,
Department Personnel Orders, plantilla)
● Other financial/budget reports
Is the implementation ⚫ Yes 〇 No Submitted MOV: Newly hired CHOWS

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
of the intervention and sample outreach activities done by

linked or coordinated CHOWS
with the LGU’s Accepted MOV: Outreach activities done
primary care services by CHOWS
(i.e., BHS, RHU,
CHO, and other
primary local health
facilities)?
Develop Personal Self Appraisal CHD Feedback

Skills Validation
Are ⚫ Yes 〇 No Submitted MOV: Certificates of trainings

training/orientations/ of CHOWS, case managers, peer
seminars/courses navigators*
provided to Accepted MOV: Photos of trainings,
implementers to orientations, seminars conducted
achieve the goals of
the intervention?
Are ⚫ Yes 〇 No Submitted MOV: Facility records; records

information/education/ and reports of CHOWS and peer
advocacy activities navigators*
conducted to improve Accepted MOV: Photos of community-
people’s knowledge, based HIV screening (CBS) training and
attitudes, and practices activity
towards resolving the
identified health
problem/s of the
intervention?
Does the health ⚫ Yes 〇 No Submitted MOV: Leaflets, posters, flip

promotion intervention chart
have its own set of Accepted MOV: Photos of Worlds AIDS
Information/Education day, International AIDS candlelight
/ Communication memorial, radio guesting
(IEC) materials?
Are the IEC materials, ⚫ Yes 〇 No Submitted MOV: Leaflets, posters, flip
capacity building chart
modules, FAQs, etc. Accepted MOV: Posters for HIV
understandable and awareness translated to local language
accessible for all?
(e.g., translated to
local
languages/dialects,
sign language
interpreter for video
materials, captioning,
etc.)
Strengthen Self Appraisal CHD Feedback

Community Action Validation

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
Are individuals/groups ⚫ Yes 〇 No Submitted MOV: AIDS ordinance,

from the marginalized attendance sheet of regional HIV partners
sectors (e.g., PWDs, meetings
IPs, LGBTQIA+, Accepted MOV: Members of Province A
indigent population, AIDS council with representatives from
women sector, etc.) vulnerable groups
involved in the
planning of the
programs?
Does the intervention ⚫ Yes 〇 No Submitted MOV: Satisfaction Survey

have a feedback Form
mechanism to elicit Accepted MOV: Satisfaction Survey Form
insights, comments,
suggestions from
target beneficiaries and
people who participate
in the
intervention/activities?
Is there involvement ⚫ Yes 〇 No Submitted MOV: RHWC data of clients

and participation of the accessing STI,HIV and AIDS prevention,
target treatment, care and support services*
beneficiaries/intended Accepted MOV: Photos of community-
audience in the based HIV screening, activity
intervention?
For questions and clarifications, an email may be sent to piod@doh.gov.ph
Validated by:
Name of Validator Name of Validator

Position Position
Office Office

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
Date of Review & Validation: ______________
City/ Province City B Region
PA 6: Sexual and Reproductive Health

Name/Title of the Health Promotion Intervention
(Please put only one program/project/policy in this checklist.)
LEGEND
Sufficient For validation For action
Priority Area CHD Validation Feedback
PA1: Diet and Exercise
PA2: Environmental
Health
PA3: Immunization
PA4: Substance Use
PA5: Mental Health Submitted Data and Parameter: Vital

Health Indices, Adolescent suicide rate
Accepted Data and Parameter: None
Feedback: Adolescent suicide rate not
reflected in the submitted document.
PA6: Sexual and Submitted Data and Parameter: Vital

Reproductive Health Health Indices, Teenage Pregnancy
Percentage
Accepted Data and Parameter: Vital Health
Indices, Teenage Pregnancy Percentage
PA7: Violence and Injury Please provide data source and parameter.
Prevention
OVERALL SCORE: 18/20
Build Healthy Public Self Appraisal CHD Feedback

Policy Validation
Is there a local policy ⚫ Yes 〇 No Submitted MOV: Ordinance No. 892 An

(i.e., ordinance/ Ordinance Institutionalizing the
resolution/EO) that Responsible Parenthood and Reproductive
supports the Health (RPRH) in City B
implementation of the Accepted MOV: Ordinance No. 892 An
health promotion Ordinance Institutionalizing the
intervention/activity? Responsible Parenthood and Reproductive

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
Is the local policy still ⚫ Yes 〇 No Health (RPRH) in City B

in effect (i.e., not
repealed by other
policies, re-issued by
current chief
executive)?
Is the local policy ⚫ Yes 〇 No

aligned with a national
law?
Does the policy have a ⚫ Yes 〇 No

background that
explains the problem/s
and the reason/s why it
should be addressed?

contain the objectives
and specific outcomes
that implementers aim
to achieve?
Does the policy state ⚫ Yes 〇 No

where the
funds/resources for the
will be coming from?

identify individuals or
offices who will be
implementing the
and what their specific
roles are?
Create Supportive Self Appraisal CHD Feedback

Environments Validation
Is there a physical ⚫ Yes 〇 No Submitted MOV: Ordinance 240

space/ environment Accepted MOV: Ordinance 240
(e.g., room, building,
street, walkway,
open/green space,
designated space/area,
etc.) that supports the
implementation and
enforcement of the
intervention?
Are these identified ⚫ Yes 〇 No Submitted MOV: Ordinance 240

spaces/environments Accepted MOV: None

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
safe, secure, and free Additional Recommendations: You may

from interference and submit the following MOVs that:
obstructions when (1) Show safety, security, privacy of
conducting an venue used for the program such
intervention/activity? as but not limited to:
○ Adequate lighting/street
lamps
○ Railings, safety barriers
○ Fire alarms, exits,
extinguishing systems
○ Evacuation plans
○ Proper ventilation systems
○ Visible warnings and
signages
○ Video and CCTV
surveillance
(2) Or, show physical accessibility of
venue used for the program such
as but not limited to:
○ Accessible entrances
○ Wheelchair ramp/lift
○ Elevators
○ Power-assisted doors
○ Toilets for PWDs
○ Adequate space for assistive
devices or personal
assistance
Is the intervention free ⚫ Yes 〇 No Submitted MOV: Ordinance 240

from Accepted MOV: None
procedures/processes Additional Recommendations: You may
that could prevent submit the following MOVs:
persons with (1) Copy of Standard Operating
disabilities or persons Procedures/ Manual of Procedures
of different (2) Non-discrimination statement or
socioeconomic policy
(3) Other documentation showing non-
class/cultural
discriminatory policies and
background/educationa procedures related to the intervention
l level from and/or providing for non-
participating in the discriminatory alternatives to these, if
intervention? applicable
(4) Summary of responses to/actions
taken to address
complaints/comments related to
difficulties in accessing the
intervention
Reorient Health Self Appraisal CHD Feedback

Services Validation
Are the human and/or ⚫ Yes 〇 No Submitted MOV: Local Expenditure

financial resources Program
needed for the Accepted MOV: Local Expenditure
implementation of the Program
intervention made Additional Recommendations:

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
available in the LGU?
Are the resources ⚫ Yes 〇 No

needed for the
implementation of the
intervention included
in the LGU’s approved
financial plans?
Is the implementation ⚫ Yes 〇 No Submitted MOV: Photo Documentation of

of the intervention implementers doing health promotion
linked or coordinated intervention
with the LGU’s Accepted MOV: Photo Documentation of
primary care services implementers doing health promotion
(i.e., BHS, RHU, intervention
CHO, and other
primary local health
facilities)?
Develop Personal Self Appraisal CHD Feedback

Skills Validation
Are ⚫ Yes 〇 No Submitted MOV: Certificate of training /

training/orientations/ orientations / seminars / courses of
seminars/courses implementers
provided to Accepted MOV: Certificate of training /
implementers to orientations / seminars / courses of
achieve the goals of implementers
the intervention?
Are ⚫ Yes 〇 No Submitted MOV: Photo Documentation of

information/education/ implementers doing information
advocacy activities education campaign
conducted to improve Accepted MOV: Photo Documentation of
people’s knowledge, implementers doing information
attitudes, and practices education campaign
towards resolving the
identified health
problem/s of the
intervention?
Does the health ⚫ Yes 〇 No Submitted MOV: IEC materials locally

promotion intervention developed for PPC in collaboration with
have its own set of ZFF and Single Drop Incorporated
Information/Education Accepted MOV: IEC materials locally
/ Communication developed for PPC in collaboration with
(IEC) materials? ZFF and Single Drop Incorporated
Are the IEC materials, ⚫ Yes 〇 No Submitted MOV: IEC materials locally
capacity building developed for PPC in collaboration with
modules, FAQs, etc. ZFF and Single Drop Incorporated
understandable and Accepted MOV: IEC materials locally
accessible for all? developed for PPC in collaboration with

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438
(e.g., translated to ZFF and Single Drop Incorporated

local
languages/dialects,
sign language
interpreter for video
materials, captioning,
etc.)
Strengthen Self Appraisal CHD Feedback

Community Action Validation
Are individuals/groups ⚫ Yes 〇 No Submitted MOV: Executive Order No.

from the marginalized 2020-56 “Organizing the City B
sectors (e.g., PWDs, Implementation Team”
IPs, LGBTQIA+, Accepted MOV: Executive Order No.
indigent population, 2020-56 “Organizing the City B
women sector, etc.) Implementation Team”
involved in the
planning of the
programs?
Does the intervention ⚫ Yes 〇 No Submitted MOV: Feedback mechanism

have a feedback form/ report
mechanism to elicit Accepted MOV: Feedback mechanism
insights, comments, form/ report
suggestions from
target beneficiaries and
people who participate
in the
intervention/activities?
Is there involvement ⚫ Yes 〇 No Submitted MOV: Photo Documentation of

and participation of the outreach activities
target Accepted MOV: Photo Documentation of
beneficiaries/intended outreach activities
audience in the
intervention?
For questions and clarifications, an email may be sent to piod@doh.gov.ph
Validated by:
Name of Validator Name of Validator

Position Position
Office Office

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438

Tel. Nos. (632) 8651-7800 locals 2823, 2830, 2829, 2827
Direct Line (632) 8743-8438

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REPUBLIC OF THE PHILIPPINES

Date of Review & Validation:_______________

City/ Province Provine A Region

Reproductive Health and Health Wellness Center (STI, HIV, and

Sufficient For validation For action

Priority Area CHD Validation Feedback

PA1: Diet and Exercise

PA4: Substance Use

PA5: Mental Health Please provide data source and parameter.

PA6: Sexual and Submitted Data and Parameter: HIV health

PA7: Violence and Injury Submitted Data and Parameter: Domestic

OVERALL SCORE: 18/20

Build Healthy Public Self Appraisal CHD Feedback

Is there a local policy ⚫ Yes 〇 No Submitted MOV: Copy of Ordinance no.

Department of Health - Health Promotion Bureau

health promotion 0679-19 series of 2019 “Province A

Is the local policy ⚫ Yes 〇 No

Does the policy have a ⚫ Yes 〇 No

Does the policy ⚫ Yes 〇 No

Does the policy state ⚫ Yes 〇 No

Does the policy ⚫ Yes 〇 No Submitted MOV: None

Create Supportive Self Appraisal CHD Feedback

Is there a physical ⚫ Yes 〇 No Submitted MOV: Photos of outreach HIV

Department of Health - Health Promotion Bureau

Are these identified ⚫ Yes 〇 No Submitted MOV: Photos of outreach HIV

Is the intervention free ⚫ Yes 〇 No Submitted MOV: Health provider

Reorient Health Self Appraisal CHD Feedback

Are the human and/or ⚫ Yes 〇 No Submitted MOV: Project Procurement

Are the resources 〇 Yes ⚫No To be considered achieved in KRA 1.4,

Is the implementation ⚫ Yes 〇 No Submitted MOV: Newly hired CHOWS

Department of Health - Health Promotion Bureau

of the intervention and sample outreach activities done by

Develop Personal Self Appraisal CHD Feedback

Are ⚫ Yes 〇 No Submitted MOV: Certificates of trainings

Are ⚫ Yes 〇 No Submitted MOV: Facility records; records

Does the health ⚫ Yes 〇 No Submitted MOV: Leaflets, posters, flip

Strengthen Self Appraisal CHD Feedback

Department of Health - Health Promotion Bureau

Are individuals/groups ⚫ Yes 〇 No Submitted MOV: AIDS ordinance,

Does the intervention ⚫ Yes 〇 No Submitted MOV: Satisfaction Survey

Is there involvement ⚫ Yes 〇 No Submitted MOV: RHWC data of clients

Name of Validator Name of Validator

Department of Health - Health Promotion Bureau

Date of Review & Validation: ______________

City/ Province City B Region

PA 6: Sexual and Reproductive Health

Sufficient For validation For action

Priority Area CHD Validation Feedback

PA1: Diet and Exercise

PA4: Substance Use

PA5: Mental Health Submitted Data and Parameter: Vital

PA6: Sexual and Submitted Data and Parameter: Vital

OVERALL SCORE: 18/20

Build Healthy Public Self Appraisal CHD Feedback

Is there a local policy ⚫ Yes 〇 No Submitted MOV: Ordinance No. 892 An

Department of Health - Health Promotion Bureau

Is the local policy still ⚫ Yes 〇 No Health (RPRH) in City B

Is the local policy ⚫ Yes 〇 No

Does the policy have a ⚫ Yes 〇 No

Does the policy ⚫ Yes 〇 No

Does the policy state ⚫ Yes 〇 No

Does the policy ⚫ Yes 〇 No

Create Supportive Self Appraisal CHD Feedback