44

Master List of Women of Reproductive Age for Family Planning Services

For the Quarter/Year: _____________________
Barangay: ___________________________ Name of BHS Midwife: _________________________ Date Prepared: ______________
No. HH No. Name of WRA Address Age in Birthday SE Status Do you plan to have If col. 7b & 7c is √, are If col 7b or 7c is WRA Based on TCL on FP,
(FN, MI, LN) Years (MM/DD/YY) more children? you currently using √ and using col. with did WRA accept any
(Place a √) any FP method? 8b or 8c, would MFP modern FP method?
you like to shift Unmet
to Modern Need
method?
(Place a √)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
15-19 20-49 1: NHTS If Yes, when? No If Yes, whatNot using Yes No (Put √ if No Yes
2: Non- type? any FP (9a) (9b) Col 9a is (11a) (11b)
NHTS Method checked) (Put
Now Spacing Limiting Modern Tradi- (Place a a √) Specify Date
(7a) (7b) (7c) tional √) modern when FP
(8a) (8b) (8c) FP method
Method accepted

10

TOTAL