MATERNAL AND CHILD HEALTH – RELATED (MCH) DATA FOR

ADOLESCENT AND YOUTH ( 10-19 YEARS OLD

REPORTING FORM
PROVINCE OF RIZAL
1. MUNICIPALITY: ANGONO 3. PERSONEL INCHARGE / DESIGNATION : Ma. RUBY D.VILLAR, RN

2. FACILITY NAME: ANGONO RHU 4. FOR THE PERIOD: 1st QUARTER 2018

Please be guided by the following instruction:

1. Indicate the name of municipality / city. ( e.g. Antipolo , Morong, etc )

2. In dicate the name of facility .( e.g Cainta rhu 1 San Mateo RHU II , San Isidro BHS)
3. Indicate the name of Personel In- charge of report presentation/ consolidation. Also indicate designation of personel .(e.g Juan Dela Cruz/PHN ,
Juana Dela Cruz /RHM)
4. Indicate the reporting period and year. Reporting period should be per quarter (e.g Jan- march 2015)
5. For Part A, B , and C indicators , fill the data being asked by sex M/F and the age group ( 1-, 14-15-19). Indicate zero(O) if NONE.
6. For source of Data , put check under TCL if the data is based on Target Client List , Otherwise , Indicate the source of data under, OTHERS (I,E
attendace sheet , logbook).

Program Indicators 10-14 years old 15-19 years old TOTAL Source of Data
(others, Specify )
M F M F M F TCL OTHERS
1, Number of adolosent
and youth provided with
FP information/RH 0 1 0 91 0 92 √
Counseling
2, Number of pregnant 1 √
adolescent and youth 102 103
provided with FP/RH
information
3, Number of Adolescent Pills 0 Pills 31 Pills 31
and youth using any FP Injectable 0 Injectable 55 Injectable 55
method during this Iud 0 Iud 2 Iud 2
period. Cm 0 Cm Cm 0

BBT 0 BBT 0 BBT 0

SDM 0 SDM 0 SDM 0
LAM 0 LAM 7 LAM 7
CONDOM 0 CONDOM 2 CONDOM 2
IMPLANT 0 IMPLANT 0 IMPLANT 0

4, Number OF Pregnant √
adolescent and youth
who had their first 0 1 0 54 0 55
antenatal care during 1st
trimester.
5, Number Of
adolescents and youth 0 0 0 37 37
who gave birth during
this period
6, Number of adolescent
and youth who gave 0 0 0 0 0 0
birth by place of Delivery
 RHU 0 RHU 0 RHU 0 0
HOSPITAL 1 HOSPITAL 31 HOSPITAL 32 25 √

BHS 0 BHS 0 BHS 0 0 √

LYING IN 0 LYING IN 3 LYING IN 3 0
HOME 0 HOME 2 HOME 2 0
OTHERS 0 OTHERS 0 OTHERS 0 0
7, Number of adolescent
and youth who had fetal 0 0 0
death during this period

Prepared By : MA. RUBY D VILLAR, RN.

(Signature over Printed name)