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BADAC DATA CAPTURE FORM 4

UNIFIED BARANGAY REPORT ON REFERRAL ACTION (UBRRA)

Data provided herein are those recorded within the months of: January to June (___) July to December (____) Year (YYYY): __________________________
INDICATOR NO. OF SURRENDERERS INDICATOR NO. OF REFERRED SURRENDERERS

MALE FEMALE TOTAL MALE FEMALE TOTAL

BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18

Submission of Updated Submission of Updated

Number of Residents Number of Referred
who Surrendered Surrenderers

INDICATOR STATUS STATUS AND NO. OF ASSESSED SURRENDERERS INDICATOR WELLNESS NO. OF SURRENDERERS ENROLLED IN WELLNESS & RECOVERY
/ LEVEL & INTERVENTIONS
OF RISK RECOVERY
MALE FEMALE TOTAL INTERVENTI MALE FEMALE TOTAL
ON S
BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18 BELOW 18 ABOVE 18

Submission of Low Submission General

Updated of Updated Interventions
Number of Number of
Assessed Mild Enrolled Community
Surrenderers Surrenderers based
Treatment &
Rehab

Moderate Health Facility

based
Outpatient
Treatment &
Rehab

Severe Inpatient
Treatment &
Rehab
 INDICATOR NO. OF SURRENDERERS WHO COMPLETED WELLNESS
& RECOVERY INTERVENTIONS

MALE FEMALE TOTAL

BELOW 18 ABOVE 18 BELOW 18 ABOVE 18

Submission of Updated
Number of Surrenderers
Who Completed Wellness &
Recovery Interventions
The purpose of this form is to determine the number of surrenderers per semester (January June, July-December), and monitor
number of who, among those surrenderers, have been referred, assessed, and who have completed any Wellness and Recover
Program interventions within the 6-month time frame. Counting shall restart at the onset of the new semester; meaning, the data
those who surrendered in the previous semester shall no longer be accounted in the next, regardless of whether they have been
referred or assessed in the following semester.