NAME OF BARANGAY: ________________

NR NAME OF DRUG PERSONALITY ADDRESS CATEGORY STATUS REMARKS

LAST NAME FIRST NAME MIDLE NAME ALIAS F P U

________________ _____________________
BADAC CHAIRMAN BARANGAY CHAIRMAN

BADAC Member: ______________________

______________________
______________________
______________________
______________________

Note for filing up the form

1. Category : Provide Check on the space provided above: P – Pusher, F- Financier, U- User
2. Status : Write Active or Inactive
3. Remarks : Write ”R” if drug personality is residing in the community or “T” if Transient drug personality