Local Health Support Division

1. Division Performance Commitment and Review - LHSD

2. Risk and Opportunities Template 2021

FORMS

1. DOH Feedback Reporting Form 

2. Inventory of LGUs with Trained Health Personnel on DOH Programs 

3. Inventory of LGUs Health Personnel on DOH Programs 

4. Technical Assistance Plan 

5. Monitoring Plan 

1. Learning & Development 

2. Needs Assessment for ISOQMS Committees 

1. MBFHI Monitoring and Assessment 

2. Conduct of Lactation Management Training 

3. Assessment Tool for Technical Assistance Packages of RMNCAHN Programs 

4. Unified Screening Tool for Adults

5. Unified Screening Tool for Children

6. Unified Screening Tool for Adolescents

7. PIR Health Facility Monitoring Checklist 

8. Annex 1 (Narrative); Annex 2 (Summary Report) 

9. EPI Data Validation Matrix 

10. Rapid Coverage Assessment (RCA) Forms 

11. EPI Vaccine Stock Card 

12. EPI Vaccine/Logistics Inventory 

13. EPI Logistics Computation Worksheets 

14. EPI Skills Performance Matrix 

15. Community Catch-Up of Under 5 Matrix 

16. Identification of High Risk Areas (REP) 

17. Reaching Every Purok Supervisory Plan 

18. Reaching Every Purok Worksheets 2-4 

19. MR OPV Microplanning Worksheets 1-4 

20. Cold Chain Tracking Matrix 

21. EPI Bi-Monthly Report Matrix 

22. EPI Monitoring Checklist 

23. Checklist for Hospital Implementation of FHN 

24. Masterlist of Children Eligible for GP 

25. Assessment Guide during Field Supervision 

26. Checklist for Desk Interview 

27. Checklist for Plan Review 

28. Client Satisfaction Rating 

29. Family Health and Nutrition Cluster Provincial Data 

30. Health Facility Feed backing Checklist 

31. Logistics Monitoring Checklist 

32. Program Reports Checklist 

FORMS - EPI

1. Kalusugan Pangkalahatang Point Persons Spesific Tasks and Roles Target and Accomplishment

2. Checklist for Hospital on the Implementation of the Family Health and Nutrition Programs 

3. FHNC Integrated Monitoring Tool for Health Center 

4. Intra-Campaign Monitoring Tools for MR Mass Immunization 

5. Intra-Campaign Monitoring Matrix for Regional Monitors 

6. EPI Accomplishment Report 

7. MNCHN Data Validation Form 1 

8. MNCHN Data Validation Form 2a 

9. MNCHN Data Validation Form 2b 

10. MNCHN Data Validation Form 2c 

11. MNCHN Data Validation Form 2d 

12. Rapid Coverage Assessment 

13. Monitoring Tool for MR OPV MI 

FORMS - NBS

1. Evaluation Tool for the Newborn Screening Facility (NSF) 

2. Revised NSF Reporting Form1 – For NSF to be submitted to PHO/CHO 

3. List of screened Patients for DOH Provided Expanded Newborn Screening Kits 

4. Evaluation Tool for NBS Practicum 

5. Data Validation Form 

6. Post L & D Intervention Evaluation Form 

7. Learning and Development Needs Assessment for Newborn Screening (NBS) Program Implementation 

8. Community-based Newborn Screening (NBS) Service: Evaluation Tool for Regional Monitors 

9. Consent Form (Training Participants

10. Parent Consent Form

11. Newborn Screening (NBS) Training Progress Report

12. NBS Kits Tracking and Inventory Form

13. Newborn Screening (NBS) Program monitoring Report

14. Evaluation / Assessment Checklist for Certification of NBS Satellite Clinics

FORMS - NIP

1. School-based Immunization Monitoring Tool 

2. National Immunization Program Routine Forms 

3. Measles Outbreak Monitoring Form 1. Regional Monitoring  Tool for PHO/HUC 

4. Measles Outbreak Monitoring Form 2. Regional Monitoring  Tool for Hospitals 

5. Measles Outbreak Monitoring Form 3. Regional Monitoring  Tool for RHU/Health Centers 

6. Measles Outbreak Monitoring Form 4. Regional Monitoring  Tool for Schools 

7. Measles Outbreak Monitoring Form 5. Campaign Implementation Phase Monitoring 

8. Online Supervisory Tool for LGU

9. Monitoring Tool for Immunization Activities and Campaigns

10. Annex A: Recording Form Catch-up Immunization Activity

11. Annex B: Reporting Form for Catch-up Immunization Activity 

12. City/Municipal Level Readiness Monitoring and Assessment Tool for boPV Intensive Catch-up Immunization 

FORMS - MNCHN

1. Guide for the Establishment of Technical Assistance Package for MNCHN Programs in Hotspots of Region 6 

2. Evaluation Tool for Implementation of Technical Assistance Packages on RMNCAHN Program 

3. Integrated FHN Monitoring Guide for Follow-up Visit 

FORMS - FP Part 1

1. Process on the Certificate Recognition as “Training Centers of DOH on Modern FP Methods”

2. Process on the Certification of Free-Standing Family Planning Clinics

FORMS - FP Part 2

1. Family Planning Program Monitoring Tool 

2. Women & Reproductive Age (WRA) tracking Tool 

3. Registry of clients for Progestin Subdermal Implant Insertion and /or Removal 

4. Registry of clients for Intrauterine Insertion and /or Removal 

5. Monitoring Tool for the Implementation for Family Planning Program in Hospitals 

6. Training Plan for the Conduct of Training on MFP Service (FPCBT 1 PPIUD etc.) 

7. Demand Generation Plan 

8. Post Training Plan on (PPIUD, Interval IUD etc.) 

9. Monitoring Checklist for FP Training Provider 

FORMS - NSMP

1. Monitoring Tool for Safe Motherhood Program in Hospitals 

2. Monitoring Tool for Safe Motherhood Program in Birthing Units 

3. Maternal Death Review Process Monitoring Toll 

4. Plano sa Paghahanda sa Oras ng Panganganak at Emerhensiya

FORMS - PHPDC

1. Blended Accreditation Process (Onsite-Online) of MBFHFI (Mother and Baby-Friendly Health Facility Initiative)

2. MBFW ( Mother and Baby-Friendly Workplace) Certification Process

3. Public Health Program Development Cluster Weekly Activity and Accomplishment Report 

4. PBUR and PR Tracking Analysis Report

FORMS - AHDP - FHNS

1. kNOw Tell Client FormsIndividual Treatment Record (Form 1) 

2. Robinsons Health Profile 

3. DM 2017-0098-Adolescent Friendly Health Facility Standard Monitoring Tool

4. Adolescent Health and Development Program Monitoring Tool

FORMS - FHN CLUSTER

1. Assessment Tool for Technical Assistance Packages of RMNCAHN Programs

FORMS - HLGP

1. Maternal Mortality Report Form 

2. Neonatal/Infant Mortality Report  Form 

3. Coaching Session Contact Report 

4. Infant Death Reporting Form 

5. HLGP Monitoring Form 

1. Smoking Cessation Clinic Monitoring Tool 

2. Integrated NCD Monitoring Checklist 

3. Visual Acuity Registry for School Children in Western Visayas 

4. Matrix of Senior Citizen Immunization Monitoring Tool 

5. Learning and Development Needs Survey/Assessment 

6. DOH-WV CHD Substance Abuse Prevention Program Monitoring Tool for UHC Implementation Sites  

7. Access and Utilization of Cervical Cancer Prevention and Screening Service 

8. Philippine Package of Essential Non-Comnunicable Disease Intervention (PhilPEN) 

9. Learning & Development neds assessment (LDNA) for National Voluntary Blood Services Program (NVBSP) Implementation 

10. DOH WV CHD Cardiovascular Diseases and Diabetes mellitus Program monitoring checklist for setting up of Cardiovascular Diseases and Diabetes mellitus Clubs

11. Monitoring Checklist for NCD LRD Programs 

12. DOH Western Visayas CHD NVBSP Monitoring Tool for BSPs

13. DOH Western Visayas CHD NVBSP Monitoring Tool for (P/CHO and LGUs)

14. Medical Assessment Form for DOH WV CHD Employees

15. Success Indicators/ Monitoring Tool for Project Site: Screening Assessment and Management of Hypertension and Diabetes

16. Monitoring Checklist for INCDPCP Program

1. Facility Quarterly Report on TB laboratory Activities 

2. Quarterly Report on Children Screened 

3. Quarterly Report on All TB Cases 

4. Quarterly Report on Treatment Outcome 

5. Quarterly Report on Children 0-4 Years Old IPT 

6. Provincial/City Quarterly Reporting of All TB Cases 

7. Supervisory Checklist 

8. Self-Assessment Form 

9. National TB Control Program – Monitoring Tool for PMDT Treatment Facilities 

10. National TB Control Program –Standard Monitoring Tool and Supervision Form for PMDT TS v. 030415 

11. Assessment Checklist STI Program 

12. National Tuberculosis Control Program Programmatic Management of Drug Assistant TB Default Tracing Monitoring Tool 

13. National Tuberculosis Control Program Programmatic Management of Drug Resistant TB Integrated DOTS Monitoring DOTS Monitoring Tool 

14. Monitoring Form for Hospital DOTS  Initiatives 

15. TB DOTS Quarterly Report 

16. DOTS Compliance Assessment Tool (DCAT) 

17. System Monitoring Tool 

18. Monitoring Tool/Checklist for QA Centers 

19. Integrated Monitoring Tool for Provinces/HUCs and Health 

20. Tuberculosis in the Workplace Implementation monitoring Checklist 

21. Assessment Tool on the Integrated Delivery of TB Services (iDOTS) Phase 2 

22. KonsulTayo TB Van Request Form

23. TB Screening Form

1. Human Rabies Investigation/Validation 

2. Evaluation / Monitoring for Rabies-Free Zone / Area Declaration 

3. Certification of Animal Bite Treatment Centers (ABTC) / Animal Bite Center (ABC)

4. Monitoring of Certified Animal Bite Treatment Center (ABTC) / Animal Bite Center (ABC)

FORMS

1. Rabies Prevention and Control Monitoring Checklist 

2. Human Rabies Case Report 

3. National Rabies Prevention & 

4. Control Program Mass Dog Vaccination Coverage  

5. Monitoring Checklist for Rabies-Free Zones 

6. Canine Rabies Cases 

7. Human Rabies Case Report 

8. DOH ABTC/ABC Assessment Tool

9. Rabies Prevention and Control Program Monitoring Checklist

10. Rabies Prevention and Control Program Monitoring Checklist

1. Regional Monitoring Tool for City Health Offices / Rural Health Units (CHO/RHU)

1. Assessment Tool for the Emerging and Re-Emerging Infectious Disease Preparedness Plan for LGUs 

2. Checklist for Emerging and reemerging Infectious Diseases Preparedness for Provincial and City Health Offices

3. Checklist for Emerging and reemerging Infectious Diseases Preparedness for Hospital 

4. Response Plan for Emerging and re-emerging Infectious Diseases for Hospitals 

5. Response Plan for Emerging and re-emerging Infectious Diseases for Provincial and City Health Offices 

6. Integrated Helminth Control Program Monitoring Checklist 

7. Evaluation Tool for Skills Training on COVID-19 Vaccination

8. Assessment Tool for Implementation of COVID-19 Immunization 

9. EREID Program Regional Monitoring Tool for CHOs/RHUs/Hospitals

10. Regional Leptospirosis Monitoring Tool for Hospitals/CHO/RHU

1. Malaria Elimination Program Monitoring Checklist

1. Dengue Prevention and Control Program Monitoring Checklist 

2. Regional Dengue Monitoring Tool for Provincial Health Offices (PHO/CHO)

3. Regional Dengue Monitoring Tool for Hospitals

4. Regional Dengue Monitoring Tool City Health Offices/Rural Health Units (CHO/RHU)

1. Issuance of Environmental Sanitation Clearance (ESC) 

2. Issuance of Certificate of Suitability/Initial/Operational Clearance for Public Cemetery/Memorial Park/Private Burial Ground/Crematorium 

3. Issuance of Initial / Operational Permit to all proposed Public Cemetery/Memorial Park / Private Burial

4. Environmental Sanitation Monitoring Tool 

5. Logistic Request 

6. Learning and Development Needs Survey /Assessment 

7. Environmental Sanitation Clearance (SC) Inspection Tool 

8. Inspection Report 

9. Checklist for Suitability of Sites proposed for Special Patent 

10. Suitability of Land Proposed to be utilized as memorial Park 

11. Inspection Report for Cemetery / Memorial Park Initial Permit

12. Inspection Report for Cemetery / Memorial Park Operational Permit

13. Zero Open Defecation Monitoring Tool

14. Workplace Application Visit Tool for Infectious Disease and EOH Section Program

FORMS - EOH NLCP

1. Monitoring Checklist

1. Certification of Primary HIV Care Clinics/ HIV Treatment Hubs in Western Visayas

2. Assessment Tool for STI, HIV & AIDS Program 

3. HIV Treatment Hub/Satellite Treatment Hub Monitoring Tool 

4. National Aids and STI Prevention and Control Program (NASPCP)

5. Checklist for HIV Treatment Hub

6. HIV,AIDS and STI Monitoring Tool

7. Certification of DOH Designated HIV Treatment Facility

1. Lymphatic Filariasis elimination Program Deformity Reports 

2. Hydrocele Validation Form 

3. Neglected Tropical Diseases Monitoring  and Evaluation Form 

4. Parasite Hunting Proficiency Sheet 

5. Masterlist of Respondents for screening of Lymphatic Filariasis 

1. Masterlist of Respondents for Screening of Schistosomiasis 

2. Neglected Tropical Diseases Monitoring and Evaluation Tool 

3. Neglected Tropical Diseases Monitoring and Evaluation Tool 

1. Western Visayas Regional Health Laboratory Network Registration 

2. Final Assessment Report for the Laboratory on Quality Management System Standards

3. Assessment/Monitoring Tool for the Standards on Quality Management System in the Clinical Laboratory