Republic of the Philippines

CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.centralluzon.doh.gov.ph

WORKPLACE APPLICATION EVALUATION TOOL

Instructions: This Level 3 Evaluation is an assessment of the application of the learnings / planned activities at the workplace and how the job performance of the participants
has improved as a result of the Learning and Development Intervention (LDI) attended. This is conducted based on the given activity timeline or maximum of 6 months after
the conduct of LDI.

Name of Participant: Reyward R, Mallare Position: Nurse 1

Division: San Antonio District Hospital Cluster/Section/Unit: San Antonio District

Hospital. San Antonio
Nueva Ecija

Title of LDI: Online Training on Philippine Integrated Disease Surveillance and Response
LDI Provider: Regional Epidemiology Surveillance Unit
Online Training on Philippine Integrated Disease Surveillance and Response.
Regional Epidemiology and Surveillance Unit. To orient/update other DRU
staff /HRH on certain diseases included in the monitoring and other timely
and relevant diseases in the country; monitoring and timely submission of
reports. Give Technical Assistance to San Antonio District Hospital on their
Objectives: HESU

Date of LDI: Aug. 2- 5

2022____________

PLAN (Based on the submitted Feedback Report) ACCOMPLISHMENT

Date What
Means of What was Reason for Non- Catch-up
Activity Timeline Resources Needed Assess was Timeline
Verification not done Accomplishment Activities
ed done
Proposal and August 15-17, Proposal and/or  Attendance
recommendation 2022 Recommendation  Minutes of
of HESU Letter the meetings
DOH-CLCHD-MSD-SOP-04-00 Form10 Rev.0
 Republic of the Philippines
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.centralluzon.doh.gov.ph

establishment to
our Chief of the
Hospital.
Meeting for call of
action to establish
the HESU of San August 10, Laptops, Encoders,  Attendance of
Antonio District 2022 Manuals/Notes the meeting.
Hospital, San Minutes of
Antonio Nueva the meetings.
Ecija by the Chief
of the Hospital
 Memorandu
m of
Agreement
Provide technical among DRU
assistance in the Laptops, Encoders, staff
creation of  April 11, 2022 Manuals/Notes
Hospital
Epidemiology and
Surveillance Unit
(HESU)
 Pre-test and
 Orientation of August 15, Post-test,
other DRU staff 2022 Computer, paper,  Evaluation
regarding PIDSR printer Form,
reporting and  Activity
certain diseases Completion
included in the
monitoring.
 Assist in  April 15, 2022 Food for the  Case
establishing Care participants, Presentation
Group for case Computer, paper,  Case Action
DOH-CLCHD-MSD-SOP-04-00 Form10 Rev.0
 Republic of the Philippines
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.centralluzon.doh.gov.ph

Plan
printer  Evaluation
Form,
 Activity
Completion
investigation team.
Memorandum of
Assist in agreement from
establishing the August 17, Food for the the private
referral network 2022 participants clinics to the
for the case Chief of the
reporting. Hospital Office.

Remarks/Comments:

Evaluated/ Assessed by:

(Full Name and Signature)

Training Specialist III

Conforme:

Reyward Mallare

Employee

DOH-CLCHD-MSD-SOP-04-00 Form10 Rev.0

 Republic of the Philippines
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.centralluzon.doh.gov.ph

(Full Name and Signature)

Immediate Supervisor and Position

Date: _____________

Date: _____________

Date: _____________

DOH-CLCHD-MSD-SOP-04-00 Form10 Rev.0