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TARGET CLIENT LIST FOR FAMILY PLANNING SERVICES


No. Date of Family Serial No. Complete Name Complete Address Age/ Date of SE Status Type of Client* Source** Previous Method***
Registration (FN, MI, LN) Birth 1 - NHTS
(mm/dd/yy) 2 - Non-NHTS

(1) (2) (3) (4) (5) (6) (7) (8) (9)

10

11

12

13

14

15
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16
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TARGET CLIENT LIST FOR FAMILY PLANNING SERVICES


FOLLOW-UP VISITS DROP-OUT Remarks/ Deworming Drugs Given to 20-49 years
(Upper Space: Schedule Date of next visit / Lower Space: Actual Date of Visit) Actions old WRA
(10) (11) Taken (13)
(12)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Date Reason* Date 1st Date 2nd Status
*** dose given dose given Check (√) if
given 2 doses
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