BARANGAY HEALTH WORKERS REGISTRATION FORM

Form 01-2024
A. IDENTIFICATION
Region VI
Municipality ROXAS CITY
BARANGAY DINGINAN
Registration Number
Date of Registration 2004
Place of Registration CHO
Accreditation Number
Date of Accreditation
Place of Accreditation
B. BHW PROFILE
NAME OF BHW: ARCIGA MARITTES BILLONES
LAST FIRST MIDDLE
COMPLETE ADDRESS: CENTRO DINGINAN ROXAS CITY CAPIZ
Number Street Barangay Municipality Province
DATE OF BIRTH DEC. 15, 1967 AGE 56 SEX FEMALE CIVIL STATUS M RELIGION CATHOLIC
NAME OF SPOUSE ROBERTO L. ARCIGA AGE 62 OCCUPATION LABORER
DEPENDENTS TOTAL NUMBER DEPENDENTS
NAME OF EDUCATIONAL
RELATIONSHIP DATE OF BIRTH OCCUPATION
DEPENDENTS ATTAINMENT
REGINA B. ARCIGA DAUGHTER MAY 20, 1987 COLLEGE GRAD. FINANCE STAFF
AMELITA A. BILLONES MOTHER APRIL 2, 1942

C. SERVICE RECORD
INCLUSIVE DATES
STATION/PLACE OF ASSIGNMENT
FROM TO
MONTH DAY YEAR MONTH DAY YEAR
JANUARY 6 2000 February 6 2024 CENTRO DINGINAN

Number of Household Presently Covered______61_____

Status of Service: (Please Check)
LGU Appointment LHB Registered/Accredited Volunteer
Received Honorarium: YES NO HOW MUCH: P 400.00/MONTH Source: BARANGAY
Technical Supervisor: Name Position
D. TRAINING ATTENDED
TITTLE TRAINING DATE CONDUCTED BY:
Basic Training for Community
MARCH 15-22, 2004 CHO
Volunteer Health Workers
GAD RELATED LAWS NOVEMBER 27, 2015 CHO
GENDER SENSITIVITY TRAINING OCTOBER 20- 21, 2016 CHO
TRAINING OF BHW/ BSW ON
NOVEMBER 28, 2018 PHO
PRIMARY HEALTH CARE

E. OTHER INFORMATION
HIGHEST EDUCATIONAL ATTAINMENT HIGH SCHOOL GRADUATE
BLOOD TYPE: A+ B+ AB+ O+
Are you a member of the National Confederation of Barangay Health Workers of the Philippines Inc.? YES NO
IF YES, year started Certificate of Membership No. ID No. RX- 421
Insurance membership Phil.Health No.:112009140649 GSIS No. SSS No. Other

CERTIFIED BY: RAQUEL A. LAAB_________ MARITTES B. ARCIGA

PRINTED NAME AND SIGNATURE (BHW)

NOTED BY:_MA. FE S. SALGADO________ Date Accomplished: _DECEMBER 5,2023__________________________

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