PERFORMANCE CRITERIA CHECKLIST

GATHERING HEALTH INFORMATION EFFECTIVELY USING TSISMIS (TAMA, SIGURADO,

SAPAT, MAKABULUHANG INFORMATION SYSTEM) FOR CHAT (COMMUNITY HEALTH
ACTION TEAMS)

Trainee’s Name: ____________________________ Date: _________________

CRITERIA
YES NO
Did you?

 Gather and prepare all materials/tools and equipment needed.

 Personally, visit the client at home.

 Begin the home visit by looking for the client, greeting the
client, introducing yourself and stating your purpose.

 Once you are done with the introduction, proceed with asking
relevant questions to determine the health status of the client.
Ask probing types of questions to elicit important information.
 Wash/Disinfect hands properly

 Get the vital signs of the client like Temperature, Respiratory
Rate, Pulse Rate, and Blood Pressure. Inform the client of the
result.

 After asking probing questions, advise the client to consult with

health service providers in the Barangay Health Center/ RHU to
verify their health conditions.

 Accompany the clients in going to the nearest health care

facility for proper health check-up and assessment. Arrange
transportation, if necessary.

 After the consultation, accompany the client home. Remind the

client of the result of the consultation and the succeeding steps
to take.

 Thank the client before leaving. Update the TSiSMIS record

form. Indicate the result of verification and consultation. Report
the actions taken.
Feedback:

Trainer: _______________________________ Date: _______________________

PERFORMANCE CRITERIA CHECKLIST
 Practicing Effective and Efficient Health Teaching /Education
Trainee’s Name: ____________________________ Date: _________________
CRITERIA YES
NO
Did you?

Check the venue for health teaching/education

Gather/prepare all materials/tools and equipment needed (sanitized).

Wear a face mask and face shield. 

Let the participants find their seats as they follow health protocols ( sanitized
hands, social distancing, wearing face mask and face shield)

Introduce yourself to the participants. 

Stand in front of a podium comfortably while presenting the topic/s.

Establish rapport by adopting proper posture/gesture and eye contact and

smiling at participants. 

Stimulate the learners’ interest by asking questions or facilitate activity.

Demonstrate health protocols or practices and ask learners to follow.

Before ending the health teaching, provide a summary of the discussion.

Always thank the participants for their time, attention and participation. 
Feedback:

Trainer: _______________________________ Date: _______________________

 PERFORMANCE CRITERIA CHECKLIST
Cleaning the Barangay Health Station
Trainee’s Name: ____________________________ Date: _________________
CRITERIA
YES NO
Did you?

Gather/prepare all materials/tools and equipment needed.

Wear Disposable cap, mask, and rubber gloves.

Check ceilings and walls, remove cobwebs using cobwebber

Wipe shelves, cabinets, furniture and other surfaces using
cloth with soap and water.

Clean windows with damp cloth with soap and water.

Sweep the floor.

Mop and dry the floor

Dispose trash in prescribed waste bin.

Remove gloves, cap, and mask .

Dispose in the waste bin.

Wash hands
Dry hands with towel.
Feedback:

Trainer: _______________________________ Date: _______________________

PERFORMANCE CRITERIA CHECKLIST

CLEANING THE BARANGAY HEALTH STATION
Trainee’s Name: ____________________________ Date: _________________
CRITERIA
YES NO
Did you?

Gather/prepare all materials/tools and equipment needed.

Wear Disposable cap, mask, and rubber gloves.

Check ceilings and walls, remove cobwebs using cobwebber

Wipe shelves, cabinets, furniture and other surfaces using
cloth with soap and water.

Clean windows with damp cloth with soap and water.

Sweep the floor.

Mop and dry the floor

Dispose trash in prescribed waste bin.

Remove gloves, cap, and mask .

Dispose in the waste bin.

Wash hands
Dry hands with towel.
Feedback:

Trainer: _______________________________ Date: _______________________

PERFORMANCE CRITERIA CHECKLIST

DISINFECTING STETHOSCOPE, THERMOMETER, BP APPARATUS
Trainee’s Name: ____________________________ Date: _________________
CRITERIA
YES NO
Did you?

Gather/prepare all materials/tools and equipment needed.

Wear Disposable cap, mask, and rubber gloves.

Wipe thermometer with cotton balls with 70% alcohol from

bulb to stem

Wipe eartips and diaphragm of stethoscope using

cottonballs with alcohol

Spray disinfectant to the BP apparatus

Return to its proper place

Dispose used cottonballs and disposable gloves in

infectious waste bin

Dispose trash in prescribed waste bin.

Wash hands
Feedback:

Trainer: _______________________________ Date: _______________________

PERFORMANCE CRITERIA CHECKLIST

Sterilizing Forceps /surgical scissor
Trainee’s Name: ____________________________ Date: _________________
CRITERIA
YES NO
Did you?

Gather/prepare all materials/tools and equipment needed.

Wear Disposable cap, mask, and rubber gloves.

Decontaminate used cotton balls

Clean forceps/surgical scissor with detergent recommended by the
manufacturer and water paying attention in the parts(teeth) of the
forcep.

Rinse properly

Prepare chemical solution and normal saline solution

Soak the forcep/scissor into the prepared chemical solution completely

Rinse off with normal saline solution and allow to dry.

Place forceps to its proper place.

Remove gloves

Wash hands and dry hands

Wash hands
Feedback:

Trainer: _______________________________ Date: _______________________