USAPANG Kuntento na Pwede Pa Bagong Maginoo

Attendance Record TOTAL # of participants: _______

Source of participants (Check primary): TOTAL # given one-on-one counseling: _______
Date and Time: _______________________________________________________ BHW Masterlist CHSR TOTAL # of Current Users: _______
Venue/Facility: _______________________________________________________ POPCOM Database FP/ANC-EPI TOTAL # of New Acceptors: _______
Municipality/City and Province: _______________________________________________________ FDS TOTAL # of Other Acceptors: _______
Facilitators/HSPs: _______________________________________________________ OTHER:_________________________________ TOTAL # Referred Clients: _______

Sasagutan ng Client Sasagutan ng HSP

Gusto mo pang Nakagamit Gumagamit Nabigyan

Nabigyan ng FP
magka-anak? ka ba noon ka ba ngayon ng one-
PANGALAN method (Isulat ang Ni-refer sa ibang
KASARIAN ng FP ng FP on-one
(Participant/Mag-asawa/ EDAD ADDRESS PHONE LAGDA method, ilagay kung facility?
Mag-partner) (M or F) Hindi Hindi method? method? counsel-
NA o OA,) Isulat kung saan.
na muna Anong Anong ing ?
Kung hindi, bakit?
  method? method? 

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