Republic of the Philippines

Department of Health
EPIDEMIOLOGY BUREAU

LABORATORY AND BLOOD BANK SURVEILLANCE (LaBBS)

Reporting Form 1

Name of Facility: Facility Ownership: Government Facility Type: Hospital Maternal/ Antenatal Clinic
Mun/City: (Check one) Private Laboratory Treatment Hub
Province: TB-DOTS Clinic Social Hygiene Clinic

Year: 20__
HIV HEPATITIS B HEPATITIS C

Number of HIV Number of Number of

Number of HIV screening Number of non-reactive Number of non-reactive Number of screening tests Number of Hepatitis B Number of Hepatitis C
confirmatory results reactive/positive for reactive/positive for
tests done HIV screening tests results released to client reactive to HIV screening tests done screening tests done
Month released to client Hepatitis B Hepatitis C

MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant*

January
February
March
April
May
June
July
August
September
October
November
December
* Of females, number of pregnant (if data available) 1 of 2
Please submit your report to your respective DOH Regional Office (RO) on the 1st week of the succeeding month
Revised as of June 2016
 SYPHILIS GONORRHEA

Number of smears
Number of smears with
Number of Syphilis Number of tests reactive Number of Syphilis Number of tests reactive Number of TPPA tests for Number of TPPA tests (urethral, cervical & Number of smears with
Month screening (RPR) tests done (RPR) for Syphilis Screening (ICT) tests done (ICT) for Syphilis Syphilis done positive for Syphilis rectal) tested for
Extracellular &
Intracellular Diplococci
Intracellular Diplococci
Gonorrhea
MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant*

January
February
March
April
May
June
July
August
September
October
November
December
* Of females, number of pregnant (if data available) 2 of 2

Prepared by:
Name:
Designation:
Contact Number:
 Republic of the Philippines
EPIDEMIOLOGY BUREAU
Laboratory and Blood Bank Surveillance
Summary of possible problems encountered
1. Some blood bank facilities (facility type 8) are not in BB sheets. Blood banks should be encoded under BB sheets ONLY.
1. A. Sometimes, same Blood bank facility with counts on BOTH BB and non-BB sheets, but DIFFERENT COUNTS

2. Facilities not testing for specific STIs but have reported tests under specific STI sheet.

Example: ABCD Hospital not testing for HIV but reported HIV test counts under HIV sheet

3. HIV reactive tests and non-reactive tests should be EQUAL to total number of HIV tests done (HIV sheet).

Example: 20 HIV Tests Done = 19 Nonreactive Tests + 1 reactive Test

4. Number of tests among pregnant SHOULD NOT BE greater than the number of tests among females.

Example: Total Females = Pregnant + Non Pregnant

5. Double counting of gonorrhea test results (see sample below)

Number of smears screened for Gonorrhea: 5

Number of smears with Intracellular
and Extracellular Diplococci:
1
Number of smears with Intracellular Diplococci: 2

Note:
Reflect ALL validated data to your regional consolidation sheet
All information sent back to DOH - EB thru this tool will be considered as the validated information
 Republic of the Philippines
Department of Health
EPIDEMIOLOGY BUREAU

LABORATORY AND BLOOD BANK SURVEILLANCE (LaBBS)

Reporting Form 1

Name of Facility: MCS Facility Ownership: X Government Facility Type: X Hospital Maternal/ Antenatal Clinic
Mun/City: Z.C. (Check one) Private Laboratory Treatment Hub
Province: Zambo. City TB-DOTS Clinic Social Hygiene Clinic

Year: 2020

HIV HEPATITIS B HEPATITIS C

Number of HIV screening Number of non-reactive Number of non-reactive Number of screening tests Number of HIV Number of Hepatitis B Number of Number of Hepatitis C Number of
tests done HIV screening tests results released to client reactive to HIV confirmatory results screening tests done reactive/positive for screening tests done reactive/positive for
Month released to client Hepatitis B Hepatitis C

MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant*

January 0 0 2 0 0 0
February 3 2 185 0 0 4
March 5 5 264 0 0 6
April 9 0 377 2 0 11
May 17 0 336 0 0 7
June 6 0 335 0 0 5
July 28 4 298 0 0 3
August 36 15 305 2 0 6
September 19 4 398 2 0 16
October 10 2 356 1 0 7
November 14 1 404 0 0 5
December 14 0 326 0 0 10
* Of females, number of pregnant (if data available) 1 of 2
Please submit your report to your respective DOH Regional Office (RO) on the 1st week of the succeeding month
Revised as of June 2016
 SYPHILIS GONORRHEA

Number of smears Number of smears with

Number of Syphilis Number of tests reactive Number of Syphilis Number of tests reactive Number of TPPA tests for Number of TPPA tests (urethral, cervical & Number of smears with
Month screening (RPR) tests done (RPR) for Syphilis Screening (ICT) tests done (ICT) for Syphilis Syphilis done positive for Syphilis rectal) tested for Extracellular &
Intracellular Diplococci Intracellular Diplococci
Gonorrhea
MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant* MALE FEMALE Pregnant*

January 2 0 0 1 0 0 0 0 0
February 0 1 0 0 0 0 0 0 0
March 0 3 0 0 1 0 0 0 0
April 0 2 0 0 1 0 0 0 0
May 0 0 0 0 0 0 0 0 0
June 0 2 0 0 0 0 0 1 0
July 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
August 1 0 0 0 0 0 0 0 0
September 0 0 12 0 0 0 3 0 0 0 0 0 0 0 0
October 0 0 38 0 0 1 0 0 0 0 0 0 0 0 0
November 0 0 52 0 0 0 1 0 0 1 0 0 0 0 0
December 0 0 49 0 0 1 4 0 0 2 0 0 1 0 0
* Of females, number of pregnant (if data available) 2 of 2

Prepared by:
Name: REYBIVIEN E. PERRA, RMT.
Designation: Med Tech - I
Contact Number: 9663694203