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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): 2023
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
33 33
who Surrenderred Surrenderers

INDICATOR STATUS STATUS AND NO. OF ASSESSED SURRENDERERS INDICATOR WELLNESS NO. OF SURRENDERERS ENROLLED IN WELLNESS
/ LEVEL & & RECOVERY INTERVENTIONS
OF RECOVERY
RISK INTERVENTI
MALE FEMALE TOTAL 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 33 of Updated Interventions 33
Number of Number of
Assessed Enrolled
Surrenderers Mild Surrenderer Community
s based
Treatment &
Rehab

Moderate Health Facility

based
Outpatient
Treatment &
Rehab

Severe Inpatient
Treatment &
Rehab

INDICATOR NO. OF SURRENDERERS WHO COMPLETED

 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 the number of who, among those surrenderers, have been
referred, assessed, and who have completed any Wellness and Recovery Program
interventions within the 6-month time frame. Counting shall restart at the onset of the new
semester; meaning, the data on 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.