FORM 1

DISCLAIMER: We hereby certify that we have read and understand the Notice on Privacy and Disclosure written on the dorsal part of this Responsible Parenthood and Family Planning 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 RPFP CLASS.

4Ps House-to-House Class Number: _________________________________

Faith-Based Organization Profile only Province / Municipality: _________________________________
PMC Others, please specify __________________________________ Barangay: _________________________________
Usapan Date Conducted: _________________________________

Name of Participant/Couple (Husband & Wife)

PROFILE Modern FP User
Highest
PLEASE WRITE IN BOLD LETTERS Sex Civil Birthdate / Age Address / Household ID Number Number of Intention to Shift to Reason for Intending
Educational Method Used Type Status PARTICIPANT'S SIGNATURE
Given Name, Surname (M/F) Status (mm-dd-yyyy) (Name of Barangay) Children Other FP Method to Use FP Method
Attainment
(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 Educational Attainment Modern FP Method Used Traditional FP User: Non-Modern FP User:
Reason for Using FP / Intending to Use
(Column 3) (Column 6) (Column 8 & 9) TYPE STATUS
1 - Married 1 - No Education 6 - Vocational Artificial Methods Modern NFP Methods (Column 10) (Column 11) (Column 12)
2 - Single 2 - Elementary Level 7 - College Level 1 - Condom 5 - Vasectomy 8 - CMM/Billings 11 - SDM 1 - Withdrawal 5 - Herbal A - Expressing to Use Modern FP 1 - Spacing
3 - Widow/Widower 3 - Elementary Graduate 8 - College Graduate 2 - IUD 6 - Tubal Ligation 9 - BBT 12 - LAM 2 - Rhythm 6 - No Method B - Undecided 2 - Limiting
4 - Separated 4 - High School Level 9 - Post Graduate 3 - Pills 7 - Implant 10 - Sympto-Thermal 3 - Calendar C - Currently Pregant 3 - Achieving
5 - Live-in 5 - High School Graduate 4 - Injectable 4 - Abstinance D - No Intention to Use

Prepared by Reviewed by Validated by Approved by

_____________________________________________ ___________________________________________ & ___________________________________________ _____________________________________________ _____________________________________________

Name and Signature of Volunteer / BHW Name and Signature of Population Worker Name and Signature of Health Worker Name and Signature of MHO or FP Coordinator Name and Signature of Provincial Population Officer