Republic of the Philippines

Department of Health
REGION IV-CALABARZON CHD

LEVEL 2 and 3
Adolescent-friendly Health Facility
SELF-ASSESSMENT AND FACILITY OBSERVATION CHECKLIST
Adopted from the Department Memorandum 2017-0098: Adolescent-friendly Health Facility (AFHF) Standard Evaluation Tool
Health Facility Name: Name of the Head of the Facility:

Address: Contact No.: Date of LGU Self-Assessment:

Instruction for LGU: This form contains self-assessment for AFHF Levels 2 and 3. In the appropriate box under LGU self-assessment column,
place a mark check (√) if the health facility is (Yes) compliant or (No) non-compliant. Please do not forget to affix the names and signatures of
the health facility respondents at the last part (3rd page) of this SAF.

LEVEL 2 – AFHF Self-Assessment and Monitoring Tool

LGU Self- DOH
Item Assessment Assessment Recommendations
YES NO YES NO
Is the health facility Level 1 Adolescent-friendly
Health Facility LGU-Certified?
National Standards for Adolescent Service Package
1. Adolescents in the catchment area of the facility are aware of the health services it provides and find the facility easy to reach
and obtain services from it
o Simple signage strategically posted
indicating the facility as an “Adolescent-
Friendly Health Facility”
o Action plan for information dissemination
o Plan for outreach program / advocacy
campaign
o Available IEC materials on different family
health programs, displayed on a rack /
conspicuous place
* IEC materials should include directory of
other agencies/organizations where
services can be obtained
2. The services provided by health facilities to adolescents are in line with the accepted package of health services and are
provided on site or through referral linkages by well-trained staff effectively.
o Policy regarding flexible time schedule /
Adolescent health schedule of the facility
o Policies for the provision of adolescent
services
o Policies for payment schemes (if
applicable)
o Certificates of training on the minimum
training courses prescribed by DOH for
adolescent focal persons and other
providers
*AJA / ADEPT / Comprehensive Mgt of
Adolescent Training for HSP

Page 1 of 3 DOH AFHF-SAF-LEVELS 2-3

 o Directory of organizations – name,
address, services provided, contact
number and contact person (for referral)
o Referral logbook – name, age, address,
clinical impression, when referred, reason
for referral, result of referral
o Referral forms available
o Accomplishment Report showing the
services given at the health facility as well
as those given by other agencies,
individuals and peer counselors
3. The health services are provided in ways that respect the rights of adolescents and their privacy and confidentiality.
Adolescents find surroundings and procedures of the health facility appealing and acceptable.
o There are separate rooms for
consultation, treatment, and counseling. If
there are limited rooms, there are at least
curtains to separate each provider.
*Conversation between provider and
client cannot be heard by others
o Protocols and guidelines for patient-
provider interaction
o Policies and procedures to ensure privacy
and confidentiality is posted
o Individual records are kept in separate
envelopes
o All records are kept in a safe place,
preferably in a separate room or a filing
cabinet with lock and key
o Individual treatment Records that show
the chief complaint, findings on
examination, clinical impression and
management of clients
Is the health facility compliant (Yes) to all or
majority of items above? (If Yes, proceed and
start the Level 3 AFHF assessment below)

To be filled-up by DOH Assessment Team

Date of L2 DOH Assessment Conducted: Regional Assessment Result:
Compliant Non-Compliant
Overall Recommendations:

LEVEL 3 – AFHF Self-Assessment and Monitoring Tool

LGU Self- DOH
Item Assessment Assessment Recommendations
YES NO YES NO
National Standards for Adolescent Service Package
1. Adolescents in the catchment area of the facility are aware of the health services it provides and find the facility easy to reach
and obtain services from it
o There are leaflets containing the clinic
schedule and services which the
Page 2 of 3 DOH AFHF-SAF-LEVELS 2-3
 patients/community can bring home and
share to other community members
o IEC plan available
2. The services provided by health facilities to adolescents are in line with the accepted package of health services and are
provided on site or through referral linkages by well-trained staff effectively.
o Patient flow from admission to delivery of
services including the average time for
each step is posted in strategic places.
o Stock cards showing the delivery and
utilization of medicines, commodities for
adolescent health care
o There is a suggestion box.
o There are peer educators assisting in
clinic operations and providing services
(lectures, counseling, etc)
o Materials being used by the adolescents
in the facility
*Educational materials, musical and
sports instruments, etc
o SOP for maintenance of facility
3. The health services are provided in ways that respect the rights of adolescents and their privacy and confidentiality.
Adolescents find surroundings and procedures of the health facility appealing and acceptable.
o There is a designated person with access
to the records.
4. There is an enabling environment exist in the community for adolescents to seek and utilize the health services that they need
and for the health service providers to provide the needed services
o Copy of the Local Development Plan
o Advocacy plan showing different agency
participation (name of the agency,
resources/assistance they will provide,
the person responsible
o Policy on creation of TWG
o Schedule of meeting of TWG
o Minutes of meetings of TWG

To be filled-up by DOH Assessment Team

Date of L3 DOH Assessment Conducted: Regional Assessment Result
Compliant Non-Compliant
Overall Recommendations:

Is the Health Facility compliant (Yes) to all/majority of Yes (for endorsement to No (still for compliance of
items for Level 3 AFHF? DOH-CO) AFHF standards)
Names and Signatures of Names and Signatures of
Health Facility Respondents: DOH Assessment Team:

Acknowledged by:
Page 3 of 3 DOH AFHF-SAF-LEVELS 2-3