MASTERLIST OF 4PS AND NHTS (MEMBERS/DEPENDENTS)

BARANGAY: ________________________
ZONE/PUROK/SITIO: ______________
NAME OF BHW: ______________________________
3
NAME 4PS NHTS BIRTHDATE AGE GENDER MEMBERSHIP STATUS REMARKS
NUMBER NUMBER (mm/dd/yyyy)
M
(4Ps/NHTS)
F MEM BENIFIC DEPEN
BER IARIES DENT
F
(PWD, Transferred
In/Out, Deceased Date)

1.
2.
3.
4.
O
L
5.
6.
7.
8.
9.
10.
11.
D
12.
13.
14.
15.
E
16.
17.
18.
19.
R
#9
20.

Total No. of 4Ps: Total No. of NHTS: Total No. of Male: Date Updated:
MEMBERs: Total No. of Female:
BENEFICIARIES:
DEPENDENT:
 MASTERLIST OF WRA 9-49YEARS OLD (FEMALE)
BARANGAY: ________________________
ZONE/PUROK/SITIO: ______________
NAME OF BHW: ______________________________

NAME 4PS NHTS BIRTHDATE AGE CIVIL FAMILY PLANNING (√) OTHER REMARKS
(√/X) (√/X) (mm/dd/yyyy) STATUS
(Single,
Married,
F
(PWD,
Transferred
In/Out,

9-14 15-49
Live in)

PILL DMPA IMPLANT BT CONDO IUD

O
Deceased Date)

L
S L M
1.
2.

D
3.
4.
5.
6.
7.
8.
9.
E
10.
11.
12.
R#
13.
14.
5
15.
16.
17.
18.
Total Users of the following
Total No. of 4Ps: Total No. of Single: Pills: DMPA:
Total No. of NHTS: Total No. of Married: Implant: BTL:
Total No. of Live-in Partners: Condom: IUD:
Others: Others:
 Total No. of 15-19Y.O.:
Total No. of 20-49Y.O.:
MASTERLIST OF SENIOR CITIZEN (60YEARS OLD & ABOVE)
BARANGAY: ________________________________
ZONE/PUROK/SITIO: __________________
NAME OF BHW: ______________________________________

NAME 4PS NHTS BIRTHDATE AGE GENDER HIGH BLOOD DIABETIC OTHERS REMARKS
(√/X) (√/X) (mm/dd/yyyy)
M F AMLODI
PINE
LOSART
AN
METOPROLOL SIMVAST
ATIN
METFOR
MIN
GLICLAZI
DE
F
(PWD, Transferred
In/Out, Deceased
Date)

O
1.
2.
3.
4.
5.
6.
7.
L
8.
9.
10.
D
11.
12.
13.
E
R#
14.
15.
16.
17.
18. 8
19.
20.
Total Users of the following
Total No. of 4Ps: Total No. of Male: Amlodipine: Losartan: Others:
Total No. of NHTS: Total No. of Female: Metoprolol: Simvastatin:
Metformin: Gliclazide: Date Updated:
 MASTERLIST OF PREGNANT WOMEN/TEENAGE PREGNANT
BARANGAY: ________________________________
ZONE/PUROK/SITIO: __________________
NAME OF BHW: ______________________________________
NAME 4PS NHTS BIRTHDATE AGE CIVIL STATUS IKA PILA PILA PETSA PETSA PETSA REMARKS

F (√/X) (√/X) (mm/dd/yyyy) (Single,

Married, Live
in)
NGA PAG ANG
BUNTIS BUHI
NGA
SA LAST
NA
REGLA
SA
PANGA
NAK
SA PAG
ANAK
(Live Birth, Still
Birth, Maternal
Death, NB Death,

1.
O ANAK Abortion,
Premature)

L
2.
3.
4.

D
5.
6.
7.
8.
9.
10.
11.
E
12.
13.
14.
R
15.
16.
17.
#7
18.
Total No. of Teenage Pregnant Aging:
Total No. of 4Ps: Total No. of Single: Date Updated:
Total No. of NHTS: Total No. of Married: (10-14Y.O):
Total No. of Live-in: (15-19Y.O):
 MASTERLIST OF ADOLESCENT (10-19 YEARS OLD)
BARANGAY: _____________________________
ZONE/PUROK/SITIO: ______________
NAME OF BHW: ________________________________
NAME 4PS NHTS BIRTHDATE AGE GENDER AGE BRACKET NAME OF REMARKS
(√/
X)
(√/X) (mm/dd/yyyy)

M F LGB 10-14Y.O 15-19Y.O

GUARDIAN
F
(PWD, Transferred In/Out,
Deceased Date)

T
1.
2.
3.
O
L
4.
5.
6.
7.

D
8.
9.
10.
11.
12.
13.
14.
E
15.
16.
17.
18.
R
#6
19.
20.
21.
22.
 Total No. of 4Ps: Total No. of Male: Total No. of 10-14Y.O.: Date Updated:
Total No. of NHTS: Total No. of Female: Total No. of 15-19Y.O.:
MASTERLIST
Total No. of LGBT: OF TARGET CHILDREN (0-71Months Old)
BARANGAY: _____________________________
ZONE/PUROK/SITIO: ______________ F
NAME OF BHW: ________________________________

O
NAME 4PS NHTS BIRTHDATE GENDER AGE IN MONTHS REMARKS
(√/X) (√/X) (mm/dd/yyyy)

1.
M F 0-6 7-11 12-23 24-35 36-47 48-59 60-71
F
2.
3. L
4.
5. O
6.
7. D
8.
9. L
10.
E
D
11.
12.

R
13.
14.

E
15.
16.
17.
18.
19.
20.
21.
R #
22.
#4
23.
Total of the following Date Updated:
Total No. of 4Ps: Total No. of Male:
Total No. of NHTS: 0-6 Months: 7-11Months:
MASTERLIST OF12-23
Total No. of Female: PERSONS
Months: WITH DISABILITY
24-35 Months:
BARANGAY: ________________________________
36-47 Months: 48-59 Months:
ZONE/PUROK/SITIO: __________________
60-71 Months:
NAME OF BHW: ______________________________________

NAME 4PS NHTS ID BIRTHDATE AGE GENDER KIND OF DISABILITY

(√/X) (√/X) Number (mm/dd/yyyy)
M F ORTHO SPEE VISU HEARI INTELLE MEN CHRONIC MULTIPLE OTHERS
PEDIC CH AL NG CTUAL TAL ILLNESS DISABILITY
1.
2.
3.
F
4.
5.
6.
7.
O
L
8.
9.
10.
11.

D
12.
13.
14.
15.
16.
17.
18.
E
19.
20.
21. R
#14
 Disability as follows Date Updated:
Total No. of 4Ps:
Total No. of NHTS: MALE FEMALE MALE FEMALE
Ortho: Visual:
Speech: ENVIRONMENTAL SANITATION Intellectual:
Hearing: Chronic Illness:
BARANGAY: ________________________________
Mental: Others:
NO. OF HH ASSIGNED: _________________________
Multiple: ZONE/PUROK/SITIO: _______________________________
NAME OF BHW: ______________________________________

HEAD OF THE FAMILY 4PS NHTS SOURCE OF WATER SOURCE OF TOILET PAMAAGI PAG
(√/X) (√/X) DRINKING LABOG SA

F
LEVEL 1 LEVEL 2 LEVEL 3 WATER N WALA BASURA
POINT SOURCE COMMUNAL (naay
TIMBA/POSO/STREAM (ASA MO A NAKI GILA NAG OTHERS
FAUCET kaugalingon KIGA BAY BUBUHO
(more than 250m
(with one faucet gripo gikan
MUKUHA UG A MIT
an kalayo sa mga IMNUNON
per 4-6 water district o
balay

O
household) sarili nga poso) TUBIG?)
1.
2.
3.

L
4.
5.
6.
7.
8.
9.
10.
D
11.
12.
13.
14.
E
R
15.
16.

#10
17.
Total No. w/ Toilet: Solid Waste Disposal as follows Date Updated:

F
Total No. of 4Ps: Total No. of
Total No. of NHTS: Level 1: Total No. w/o Toilet: Burning: Compost Pit:
Level 2: Total No. w/ shared Toilet: Segregation: Buried W/ Cover:
Level 3:
MASTERLIST OF OFWs/SEAFARERs Dumping: Others:
BARANGAY: ________________________________
ZONE/PUROK/SITIO: _______________________________
NAME OF BHW: ______________________________________ O F
OFW
Male
Female
TOTAL
L O
SEAFARER
Male
Female
TOTAL
D L
E D
R E
#15 R