MATERNAL DEATH SURVEILLANCE AND RESPONSE - Reporting Form To Be Submitted To DOH

Republic of the Philippines
DEPARTMENT OF HEALTH
REGIONAL OFFICE V Bicol
Legazpi City
Trunk line (052) 204-0040, 204-0050, 204-0090, 742-1731, 742-1728
FAX local no. 104
Email address: chd_bicol@yahoo.com.ph Website: http://ro5.doh.gov.ph
MATERNAL DEATH SURVEILLANCE AND RESPONSE (MDSR)

REPORTING FORM
(Please accomplish 1 Report Form per case reviewed)
Date of Review: _____________________
REVIEW FINDINGS
Description of the case:
Age in years: _________

Race/Ethnicity:
 Please identify social or cultural affiliation, e.g. Bicolano, Cebuano, Ilocano, Ilonggo, etc.
________________________________________________________________________
 If belonging to a particular cultural community or tribe, please identify, e,g, Aeta, Manobo, etc
________________________________________________________________________.
 Religious Affiliation: ______________________________________________________
Educational Attainment: ____________________________

Socio-economic Status of Family:
 4 P’s beneficiary: ____________

 None- 4P’s beneficiary: ____________
 Philhealth member: ____________
 None-Philhealth member: ____________
 Where family lived (please provide a brief description):
____________________________________________________________________________
Gravidity: _____________________
Parity: _____________________
Gestational Age: ________________
Pregnancy Outcome: Please check
 Preterm live birth: _________

 Term live birth : _________
 Fetal death: _________
 Newborn death: _________
 Abortion : _________
Date of Death: ____________________________________

Place of Death: ____________________________________
fhc/rmcab Page 1 of 6
Legazpi City
Trunk line (052) 204-0040, 204-0050, 204-0090, 742-1731, 742-1728
FAX local no. 104
o Barangay Health Station: ______

o Rural Health Unit: ______
o Health Center: ______
o Midwife Clinic: ______
o Community Hospital: ______
o District Hospital: ______
o Provincial Hospital: ______
o Tertiary Hospital: ______
o Private Hospital: ______
o Home: _____________________
o In transit: __________________
Time of Death:
 Time of day: ________________

 Weekday: ________________
 Weekend: ________________
 Season: ________________
Antenatal Care: Please Check
 First attended ANC:
o First Trimester: ____________

o Second Trimester: ____________
o Third Trimester: ____________
 How many ANC visits? ______________

 Type of ANC provider:
o Doctor: ____________________
o Nurse: _____________________
o Midwife: ___________________
 Type of Place:

Legazpi City
Trunk line (052) 204-0040, 204-0050, 204-0090, 742-1731, 742-1728
FAX local no. 104

 No ANC: _________________________
 Distance of facility from home:
o Travel time: ___________________

o Common mode of transportation: ___________________
Delivery: Please Check
 Date of delivery: ______________________

 Time of delivery: ______________________
o Day of the week: ________________

o Season: _______________________
 Place of delivery: Please check.

o Home: ______
o In transit: _______
 Type of delivery attendant: Please check
o Doctor ______
o Nurse ______
o Midwife ______
o TBA _______
o Others: Please specify _______
 Type of delivery: Please check
Legazpi City
Trunk line (052) 204-0040, 204-0050, 204-0090, 742-1731, 742-1728
FAX local no. 104
o Normal Spontaneous _______

o Assisted Vaginal:
 Forceps _______
 Vacuum _______
o Surgical (caesarian) ________
Medical Cause of Death: __________________________________________________________
Factors that lead to death Health System Gaps

Describe the circumstances that lead to death Systemic features that could have prevented death
Legazpi City
Trunk line (052) 204-0040, 204-0050, 204-0090, 742-1731, 742-1728
FAX local no. 104
100-Day Response Plan: (Select at least 1 system gap. Make a Response Plan for every system’s gap
noted).
Identified system’s gap: _________________________________________________________________

_____________________________________________________________________________________
Results Objective: State tangible (something that can be seen) consequence, outcome or product as a
result of implementing the Response Plan.
Activities: Enumerate “things to do” that will lead to achieving the Results Objective.
Activities Result or Output Date of Conduct Who’s in charge?

Each activity should lead
to Result or Output
Legazpi City
Trunk line (052) 204-0040, 204-0050, 204-0090, 742-1731, 742-1728
FAX local no. 104
Submitted by:
__________________________________________________
Head, Provincial/City Review Team
Province/City of_____________________________________

MATERNAL DEATH SURVEILLANCE AND RESPONSE - Reporting Form To Be Submitted To DOH

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Republic of the Philippines

MATERNAL DEATH SURVEILLANCE AND RESPONSE (MDSR)

Date of Review: _____________________

Description of the case:

Age in years: _________

Educational Attainment: ____________________________

 4 P’s beneficiary: ____________

 Preterm live birth: _________

Date of Death: ____________________________________

o Barangay Health Station: ______

 Time of day: ________________

Antenatal Care: Please Check

 First attended ANC:

o First Trimester: ____________

 How many ANC visits? ______________

o Barangay Health Station: ______

o Provincial Hospital: ______

 Distance of facility from home:

o Travel time: ___________________

Delivery: Please Check

 Date of delivery: ______________________

o Day of the week: ________________

 Place of delivery: Please check.

o Barangay Health Station: ______

 Type of delivery attendant: Please check

 Type of delivery: Please check

o Normal Spontaneous _______

Medical Cause of Death: __________________________________________________________

Factors that lead to death Health System Gaps

Identified system’s gap: _________________________________________________________________

Activities Result or Output Date of Conduct Who’s in charge?

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