Republic of the Philippines

CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
centralluzon.doh.gov.ph

ANNEX 4_MONTHLY CXR VOUCHER SUMMARY REPORT

(HEALTH FACILITY/MONTH/YEAR)
No. Indicator HC Adult (15 y/o and Child (14 y/o and below)
above)
Male Female Male Female
SCREENING
1 Number of Patients Referred to CXR Provider 0 0 0 0

2 Number of Patients who AVAILED free X-ray 0 0 0 0

3 Number of Screened with (+) X-ray Result 0 0 0 0
4 Number of Screened with TB Signs and Symptoms only 0 0 0 0
5 Number of Presumptive patients identified 0 0 0 0
(Screened with (+) x-ray result and TB signs and symptoms)
DIAGNOSIS (TESTING)
6 Total no. Tested on Xpert MTB/Rif 0 0 0 0
7 No. of FINAL Xpert MTB/Rif Result: MTB NOT Detected; 0 0 0 0
Rifampicin Resistance NOT Detected (N)
8 No. of FINAL Xpert MTB/Rif Result: MTB Detected, Rifampicin 0 0 0 0
Resistance NOT Detected (T)

9 No. of FINAL Xpert MTB/Rif Result: MTB Detected, Rifampicin 0 0 0 0

Resistance INDETERMINATE (TI)

10 No. of FINAL Xpert MTB/Rif Result: MTB Detected, Rifampicin 0 0 0 0

Resistance DETECTED (RR)
ENROLLMENT TO TB TREATMENT
11 BC DSTB Cases enrolled 0 0 0 0
12 CD DSTB Cases enrolled 0 0 0 0
13 BC RRTB Cases enrolled 0 0 0 0
ENROLLMENT TO TB PREVENTIVE TREATMENT
0-4 5-14 0-4 5-14
14 No. of Contact traced from BC patients 0 0 0 0 0 0
15 No. of Contact traced from CD patients 0 0 0 0 0 0
16 No. of Contacts screened with X-ray or symptoms 0 0 0 0 0 0
17 TPT Cases enrolled 0 0 0 0 0 0
18 No. of TB Cases Notified from Contacts 0 0 0 0 0 0
PENDING
19 Xpert MTB/Rif Testing 0 0 0 0
20 BC DSTB Cases Enrollment 0 0 0 0
21 CD DSTB Cases Enrollment 0 0 0 0
22 BC RRTB Cases Enrollment 0 0 0 0
23 TPT Cases Enrollment 0 0 0 0
Remarks: Pending Testing Remarks: Pending Enrollment Remarks: (if previously screened but enrolled in the
Unable to locate- Unable to locate- current month, please provide breakdown)
Unable to expectorate- Unable to expectorate- BC DSTB –
Refused- Refused- CD DSTB –
Died- Died- BC DRTB –
TPT -
Prepared by:

Name/Designation/Signature

* Submit the CXR Provider Evaluation thru https://bit.ly/CXRProvider_EvaluationTool.

 Republic of the Philippines
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
centralluzon.doh.gov.ph

* Submit the signed copy of Summary Report at tb@centralluzon.doh.gov.ph.