DISCLAIMER:We hereby certify that we have read and understood the Notice on Privacy and Disclosure written on the

dorsal part of this Responsible Parenthood and Family Planning (RPFP) Form and by signing and submitting this, we hereby grant the
Commission on Population (POPCOM), or any of its authorized agents and partners, the authority to collect, obtain, store and process the personal information that we provide below for the purpose/s of _______________________________________.

FORM 1
4Ps House-to-House Class No.:
Faith-Based Organization Profile only Prov/City/Mun.:
PMC Others, please specify _______________________ Barangay
Usapan Date Conducted

PROFILE Modern FP User Traditional FP User

Name of Participant/Couple (Husband & PARTICIPANT'S SIGNATURE
Highest Intention to Reason for
Wife) PLEASE WRITE IN BOLD LETTERS Sex Civil Address No. of Method
Birthdate Educational shift to other Type Status Intending to use FP
(name, surname) (M/F) Status (Purok, Brgy,Province/City) Children Used
Attainment FP Method Method
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)

10

NOTE: Please use CODE NUMBER below for Civil Status, Educational Attainment and Method Used

Civil Status Highest Educational Attainment Reason for Using FP / Non-Modern FP User : STATUS
Traditional FP User : TYPE
Modern FP Method Used Intending to Use
(Column 3) (Column 6) (Columns 8 & 9) (Column 11)
1- Married 1- No Education 6- Vocational Artificial Methods: Modern NFP Methods: (Columns 12) (Column 10) A - Expressing Intention to Use Modern FP
Method (indicate CODE for Modern FP Methods
2- Single 2- Elementary Level 7- College Level 1 - Condom 5- Vasectomy 8- CMM / Billings 11-SDM 1- Spacing 1- Withdrawal 5-Herbal use col .8)
3- Widow/Widower 3- Elementary Graduate 8- College Graduate 2- IUD 6- Tubal Ligation 9- BBT 12-LAM 2- Limiting 2- Rhythm B - Undecided
4- Separated 4- High school Level 9 - Post Graduate 3- Pills 7- Implant 10- Sympto-Thermal 3- Achieving 3- Calendar 6- No Method C - Currently Pregnant
5- Live-in 5- High School Graduate 4-Injectable 4- Abstinence D - No Intention to Use
Prepared by: Reviewed by: Approved by:

___________________________________ _______________________________________ _____________________________________

Name/Signature of RPM Team Member/s Name & Signature Name & Signature of Provincial / City Population
Officer