Republic of the Philippines

DEPARTMENT OF HEALTH – Regional Office VIII

PROVINCIAL DOH OFFICE
Catarman, Northern Samar

CLEARANCE CERTIFICATE

I, __________ ___________________________________________ _ _________________ ___

(Full Name) (Position)

Of _____________________________________________________________________ _________
(RHU)

request for clearance from all accountabilities with the Provincial DOH office.

___________________ ___________________
Signature of HRH Date

Cleared as to:

DOCUMENTS POINT PERSON SIGNATURE

SAM Report (January to November) ND Assigned
MAM Report (January to November) ND Assigned
Total Number of Cured, Non Cured, Death,
ND Assigned
and Defaulter
Micronutrient Supplementation and Vitamin
ND Assigned
A supplementation (GP Report) 2nd Round
MNCHN Database (November) with TCL Venus C. Soccoro
NIP Database (November) with TCL Venus C. Soccoro
Maternal and Child Death Linelist 2022 Venus C. Soccoro
Pregnancy Tracking as of November 2022 Venus C. Soccoro
Vaccine Inventory as of November 2022 Venus C. Soccoro

Updated HEMS Annexes (As of November Lesly B. Ballesta

2022 e copy)

Hardcopy of CSBP (KIA/WIA Reports with

MOVs) January to December with signature Emie V. Dometita
of MHO
Soil- Transmitted Helminthiasis Report
(January and July) 2022 hard copy with Dream Aizyl C. Reyes
signature of MHO/PHN
Schistosomiasis Treatment Report 2022 hard
Dream Aizyl C. Reyes
copy with signature of MHO/PHN
Latest Inventory report of all DOH procured
Pharmacist Assigned
medicines and vaccines
NDHRIS signed screenshots or update form Ma. Jerrel A. Laguitan
Annual Consolidated report of FHSIS per Nissan Rio G. Sosa
 Barangay
Covid19 Confirmed Data
(History of Exposure, Occupation, workplace Nick Andrew D. Cardenas
and Vaccination Status)
Covid19 Death Line List (With death and
Nick Andrew D. Cardenas
time of death and Final diagnosis)
Larval Survey (January to November) Hard
Nick Andrew D. Cardenas
copy and e-copy
Form B Covid Vaccine Inventory Pharmacist Assigned
NIP report for January to November 2022
Rommel C. Lipata
e-copy or Hard copy

Recommending Approval:

_______________________
DMO

Approved:

ROMMEL C. FRANCISCO, MD, MPH

Provincial DOH office