HSCMDA-ANNEX E

HSCMDA Barangay Masterlist and Recording Form (For STH Areas)

Community-Based MDA (12-59 months 1-4 years old)

Region: ____IV=A_______ Soil-Transmitted Helminthiasis Albendazole (ALB) for 1-4 y/0

Province/City: ___BATANGAS___

Municipality/District: ____IBAAN______

Barangay: ____COLIAT______

No. SURNAME GIVEN NAME SEX Age in DATE OF BIRTH House Number of Drug DATE GIVEN REMARKS
Years Number and Given (dd/mm/
Street yy)
ALB(1-2 ALB (2-
M F y/o or 12- 4 y/o)
23 mos)

1
2
3
4
5
6
7
8
9
10

Accomplished by: Verified by: Date Accomplished:

_______________________________________ ____________________________________ __________________________

Rural Health Midwife (RHM) Public Health Nurse dd/mm/yy
 To filled up at the Main Health Center (MHC) and Barangay Health Station or Center (BHS/BHC)