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BADAC DATA CAPTURE FORM 4

UNIFIED BARANGAY REPORT ON REFERRAL ACTION (UBRRA)

Data provided herein are those recorded within the months of: January to June ( ) July to December ( ) Year (YYYY): __________________________

NO. OF SURRENDERERS NO. OF REFERRED SURRENDERERS

INDICATOR INDICATOR
MALE FEMALE MALE FEMALE
TOTAL TOTAL
BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18

Submission of Updated
Submission of Updated Number
Number of Residents who
of Referred Surrenderers
Surrenderred

WELLNESS & NO. OF SURRENDERERS ENROLLED IN WELLNESS &

STATUS / STATUS AND NO. OF ASSESSED SURRENDERERS
RECOVERY RECOVERY INTERVENTIONS
INDICATOR LEVEL OF INDICATOR
INTERVENTION
RISK MALE FEMALE MALE FEMALE
TOTAL S TOTAL
BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18

General
Low
Interventions

Community-
Mild Submission of based Treatment
Submission of
Updated & Rehab
Updated Number
Number of Health Facility-
of Assessed
Enrolled based Outpatient
Surrenderers Moderate Surrenderers Treatment &
Rehab
Inpatient
Severe Treatment &
Rehab

NO. OF SURRENDERERS WHO COMPLETED WELLNESS The purpose of this form is to determine the number of surrenderers per semester (January-
& RECOVERY INTERVENTIONS
INDICATOR June, July-December), and monitor the number of who, among those surrenderers, have
MALE FEMALE been referred, assessed, and who have completed any Wellness and Recovery Program
TOTAL
BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 interventions within the 6-month time frame. Counting shall restart at the onset of the new
Submission of Updated semester; meaning, the data on those who surrendered in the previous semester shall no
Number of Surrenderers Who longer be accounted in the next, regardless of whether they have been referred or assessed
Completed Wellness & in the following semester.
Recovery Interventions