CBMIS Barangay Tally Sheet

Family Planning Program

____________

Barangay: _________________________
BHS/BHC: ________________________ RHM: ________________________
Mun./City: ________________________ Date: _________________________
Page 1
BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
A. FAMILY PLANNING AND MARRIED WOMEN OF
REPRODUCTIVE AGE (MWRA)
1. Menopausal MWRA (15-49 y/o)/had hysterectomy
2. Pregnant Women
3. MWRA NOT USING and NOT INTERESTED in
using any family planning method
4. MWRA NOT USING any family planning method
BUT INTERESTED to use a TEMPORARY
method
5. MWRA NOT USING any family planning method
BUT INTERESTED in Tubal Ligation (BTL)
6. MWRA NOT USING any family planning method
BUT partner INTERESTED in VASECTOMY
7. MWRA USING a family planning method
SATISFIED with the method she is using
8. MWRA USING a family planning method but NOT
SATISFIED with the method she is using
Total number of MWRA
(sum of # 1 & 8)
FP METHODS USED BY CURRENT USERS
Female Sterilization (Tubal Ligation)
Male Sterilization (Vasectomy)
Pill
Intrauterine Device (IUD)
Injectables (DMPA)
Mucus/Billings/Ovulation Method
Basal Body Temperature
Symptothermal
Standard Days Method (SDM)
Condom
Lactational Amenorrhea Method (LAM)
Calendar/Rhythm/Periodic Abstinence
Withdrawal
Total Current Users by FP Methods Used
(Should equal the sum of # 7 & 8)
 Family Planning Program

Page 2
BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
B. PRIVATE SECTOR SOURCES OF FP SERVICE/
SUPPLY OR ADVICE ON METHOD USE
9. Private Hospital/Clinic
10. Pharmacy
11. Private Doctor
12. Private Nurse/Midwife
13. NGO
14. Industry-based Clinic
Total Current Users by Private Sector Sources
(sum of # 9 to 14)
C. PUBLIC SECTOR SOURCES OF FP SERVICE/
SUPPLY OR ADVICE ON METHOD USE
15. Government Hospital
16. Rural/Urban Health Center
17. Barangay Health Station
18. Brgy. Supply Officer/Service Point Person/BHW
Total Current Users by Public Sector Sources
(sum of # 15 to 18)
D. OTHER SOURCES OF FP SERVICE/
SUPPLY OR ADVICE ON METHOD USE
19. Puerculture Center
20. Store
21. Church
Total Current Users by other sources
(sum of # 19 to 21)
E. REASONS FOR DISSATISFACTION WITH
THE CURRENT FP METHOD
22. Husband Disapproves
23. Side effects
24. Health concerns
25. Difficult
26. Costs too much
27. Inconvenient to use
28. Other reasons
Total number of Dissatisfied Current Users by
reason of Dissatisfaction (sum of # 22 & 28)
 CBMIS Barangay Tally Sheet
EPI and Vitamin A Supplementation Program

Barangay: ____________________________
BHS/BHC: ___________________________ RHM: _______________________
Mun./City: ___________________________ Date: ________________________

TARGET GROUP BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
I A. VACCINATION STATUS OF CHILDREN
0-11 MONTHS OLD
1. Children 9-11 months old with INCOMPLETE or
NO vaccination at all
2. Children -8 months old with NO vaccination or
with recommended vaccination schedule NOT
followed
3. Children 0-8 months old with recommended
vaccination schedule followed
4. Children 9-11 months old who are fully
immunized Children (FIC)
TOTAL number of children -11 months old
(sum of # 1, 2, 3, & 4)
I B. VACCINATION STATUS OF 1 YEAR OLD
CHILDREN (12-23 MONTHS)
5. Children 1 year old (12-23 months) with
INCOMPLETE or NO vaccination at all
6. Children 1 year old (12-23 months) who are Fully
Immunized Children (FIC)
TOTAL number of 1 year old children (12-23
months) (sum of # 5 & 6)
II A. VITAMIN A SUPPLEMENTATION
STATUS OF CHILDREN 6-11 MONTHS OLD
7. Children 6-11 months old NOT given Vitamin A
8. Children 6-11 months old given Vitamin A capsule
TOTAL number of children 6-11 months old
(sum of # 7 & 8)
II B. VITAMIN SUPPLEMENTATION STATUS OF
CHILDREN 1-5 YEARS OLD (12-71 MONTHS)
9. Children 1-5 years old (12-71 months) NOT
given Vitamin A capsule in the last six months
10. Children 1-5 years old (12-71 months) given
Vitamin A capsule in the last six months
TOTAL number of children 1-5 years old (12-71
months) (sum of # 9 & 10)
 CBMIS Barangay Tally Sheet
Tuberculosis Control Program

Barangay: ____________________________
BHS/BHC: ___________________________ RHM: _______________________
Mun./City: ___________________________ Date: ________________________

TARGET GROUP BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW BHW Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
A. PERSONS CURRENTLY WITH SYMPTOMS
ASSOCIATED WITH TB
1. But did NOT seek consultation or treatment
2. Sought consultation/treatment in the private sector
3. Sought consultation/treatment in the public sector
Total number of persons currently with
symptoms Associated with TB (sum of # 1 to 3)
B. TREATMENT STATUS OF PATIENTS
4. NOT undergoing TB treatment
5. Undergoing TB treatment
Total number of TB patients
(sum of # 4 & 5)
C. PRIVATE SOURCES OF ANTI-TB DRUGS
6. Private Hospital/Clinic
7. Pharmacy
8. Private Sector
9. NGO Clinic
Number of TB Patients getting anti-TB drugs
from Private Sources (sum of # 6 to 9)
D. PUBLIC SOURCES OF ANTI-TB DRUGS
10. Government Hospital
11. Rural/Urban Health Center
12. Barangay Health Station
13. Outreach Clinic
Number of TB Patients getting anti-TB drugs
from Public Sources (sum of 10 to 13)
E. TREATMENT PARTNERS
14. No treatment partner
15. Health Professional
16. Barangay Health Workers
17. Community Leaders/Volunteers
18. Friends/Neighbors
19. Family/Relatives
Number of TB Patients by
Treatment partner (sum of # 4 to 9)