Annex 

1: M1 Report
FHSIS REPORT for the MONTH :____________ YEAR :________

M1
Name of Hospital :____________________________________ Age Disaggregation of Current
Address :____________________________________ Users
FP Point Person :____________________________________ (end of the Month)
Province
Region
:____________________________________
HSPTL
Current User Acceptors New
(End of
New Other Dropout Current User Acceptors
Previous 14 and
FAMILY PLANNING METHOD Acceptors Acceptors (Present (End of of the 15-19 20-49
Month / Below
Month) Current Month) present
Beginning of (Previous (Present
Month
the Month) Month) Month)
a. Female Sterilization / BTL
b. Male Sterilization / Vasectomy
c.1 Pills-POP
c.2 Pills-COC
d.1 I-IUD (Interval IUD)
d.2 PP-IUD (Post-partum IUD)
e.1 Injectables-POI
e.2 Injectables-CIC
f. NFP-CM (Cervical Mucus)
g. NFP-BBT (Basal Body Temperature)
h. NFP-STM (Symptothermal Method)
i. NFP-SDM (Standard Days Method)
j. NFP-LAM (Lactational Amenorrhea Method)
k. Condom
l. Progestin-only Subdermal Implant
Total

Prepared by:
(Name of Signature)
Position:
Date:

Approved by:
(Name of Signature)
Position:
Date: