PERFORMANCE BASED FINANCING (PBF)

COMMUNITY VERIFICATION
COMMUNITY BASED ORGANIZATION (CBO) ACTIVITIES REPORT FORM
I. IDENTIFICATION

Name of CBO: ………………………………………..…………………………

Number of Members of the CBO. Number of Members trained in the PBF:

Number of Contracts already signed: Number of Quarters suspended:

Period Covered by Present Contract: ……/……/20… To……/……/20…

Quarter concern with Data Collection: ……/……/20… To……/……/20…

II. Total number of Questionnaires Received:

S/N SAMPLED INDICATORS QUANTITY HEALTH FACILITY

1.
2.
3.
4.
5.
6.
7.
TOTAL
Date of CBO Reception of Questionnaires: ……/…/20.…
III. Total Number of Questionnaires Returned by CBO and Received by the CDVA:
Total
Properly Not Not
S/N INDICATORS Returne
Filled. Found Returned
d
1.
2.
3.
4.
5.
6.
7.
TOTAL

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Expected Date of returning the questionnaires by the CBO: ……/…/20.…
Actual date of bringing back the questionnaires by the CBO: ……/…/20.…
IV. SWOT ANALYSIS

A. STRENGHTS (Internal Factors That Make The Work Easy)

B. WEAKNESSES (Internal Factors That Make The Work Difficult)

C. OPPORTUNITIES (External Factors Exploited that make the work Easy)

D. THREATS (External Factors Beyond CBO control that affects the work)

V. FIELD AGENTS EVALUATION BY CBO SUPERVISOR.

S/N NAME OF FIELD AGENT PHONE TRAINED NUMBER OF NUMBER OF NUMBER OF
NUMBER OR NOT QUESTIONNAIRES PATIENTS PATIENTS
TRAINED RECEIVED. FOUND. NOT FOUND
1.
2.

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 3.
4.
5.
VI. RECOMMENDATIONS:

A. RECOMMENDATIONS TO THE CBO MANAGEMENT

B. RECOMMENDATIONS TO THE HEALTH FACILITIES

C. RECOMMENDATIONS TO THE PBF OFFICE (CDVA).

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 VII. LIST OF PATIENTS NOT FOUND AND THE REASONS:

EFFORT MADE
(PHONE CALL and INDICATOR
S/N NAME OF PATIENT/GAURDIAN POSSIBLE REASON FOR NOT FOUND
HOUSEHOLD INVOLVED.
VISIT).

SURMARY FEEDBACK FROM PATIENTS FOR THE HEALTH FACILITY

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POSITIVE FEEDBACK POINTS NEGATIVE FEEDBACK POINTS

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Prepared By (CBO FIELD AGENT(S)): Reviewed and Approved By (CBO And Validated By (CDVA SUPERVISOR):
SUPERVISOR):
DATE:
DATE: DATE:

SIGNATURE SIGNATURE SIGNATURE

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