BARANGAY HEALTH STATION SITE SCREENING FORM

This form will be used in aid of the selection of the sites for the barangay health station (BHS) which HFI is planning to
build within the year. Please fill in the areas with details asked and check ( ✓) the box that best reflects your answer.
Please be assured that your replies will be treated with utmost confidentiality. Thank you so much.

I. Barangay Health Profile

Barangay: Municipality:
Contact Person of the BHS: Name of Respondent:
Contact No./e-mail
Contact No./e-mail address:
address:
No. of Sitios/Puroks:
No. of individuals:
Population
No. of households:
Quality of roads:
Modes of transportation
Transportation
available:
Distance from población (km):
No. of BHS Personnel Midwife:
Indicate how many individuals BHW:
per personnel type are assigned BNS:
to the barangay Others:
BHW and BNS duty schedule per week:
Days No. of BHWs on Duty Time
Duty
Monday
Tuesday
Wednesda
y
Thursday
Friday
Saturday
Sunday
BHS Operating Schedule:
Indicate days of the week and daily hours
Average no. of patients seen per day:
Community Profile: Please attach a copy of the barangay’s community profile

II. Health Indicators (for the year ______)

1. Maternal mortality rate:
2. Infant mortality rate:
3. Child mortality rate:
4. Proportionate mortality from preventable disease across all age group:
5. Rate of children with complete vaccination (EPI):
6. Rate of infants exclusively breastfed:
7. Number of cases of malnutrition:
8. Number of households with access to clean
water:
9. Number of households with own toilets:
10. List of common/endemic illnesses in the
barangay:
11. Priority health projects of the barangay:
12. Referral System Distance (km) Travel time (mins.) Mode of transportation
How far is the present BHS from the nearest BHS of
neighboring barangays?
How far is the present BHS from the RHU?
What is the nearest referral hospital for complicated
cases and how far is the present BHS from said
hospital?

III. Catchment Information

Population Mode of With BHS with
Name of Neighboring State of BHS
No. of No. of transportation BHS? midwife?
Barangays (Good/Poor)
Individuals Households to barangay (Yes/No) (Yes/No)
IV. Barangay Assessment
Always Often Rarely Never
(Lahat ng oras) (Madalas) (Madalang) (Hindi kailanman)
1. Barangay captain initiates health policies and programs at the barangay-level to improve the health
status of the community
2. Barangay captain ensures implementation of health-related activities/programs of the municipal
health office in their barangay.
3. Barangay captain collaborates and engages participation of the community in the decision-making
of all health-related activities/programs in their barangay.
4. Local government demonstrates accountability through regular monitoring and evaluation reports
of implemented projects and programs
5. Local government is transparent and opens full disclosure of their meetings and budgets for public
review.
YES NO
6. Is there an available piece of land for construction that can be either government-owned or donated land?
a.) In a location that is accessible to the target beneficiaries
b.) Safe from environmental hazards such as:
- Not located at the edge of a slope
- Not located at a seismic faultline
- Not located near the foot of a mountain
- Not located near bodies of water (at least 100m away)
- Not on a reclaimed site
- Not located in a flood-prone area
- Not within the 14km radius danger zone for a volcanic eruption
c.) Size of lot is at least 220 sqm. (11 m x 20 m)
d.) Shape of lot is rectangular
e.) With access to electricity supply
f.) With access to running source of water
7. Barangay is not a prospective site of DOH HFEP

Accomplished by:

Full Name and Signature

Date: