FHSIS REPORT for the YEAR: _______

Name of Municipality/City: __________________________________

Name of Province: __________________________________
Projected Population of the Year: __________________________________
For submission to PHO/CHO

Section A. Family Planning Services and Deworming for Women of Reproductive Age
A1. Modern FP Unmet Need Age Total for WRA 15-49 y/o Interpretation
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 y/o 15-19 y/o 20-49 y/o
1. Proportion of WRA with unmet need for modern FP
(No.1.1/No.1.2 X 100)
1.1 Number of WRA with unmet need for MFP - Total
1.2 Total No. of Estimated WRA
(Total Population X 25.854%)
A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors CPR
(Beginning of Qtr) New (end of Qtr) Other (end of Qtr) (Present Quarter) (End of Quarter) (Last Month of Col. 6/TP x 25.85
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) Present Qtr) (Col. 7) (Col. 8)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
a. BTL -Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI) - Total
f. Implant - Total
g. IUD (IUD-I and IUD-PP) - Total

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g.1 IUD-I- Total

g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
 Section B. Maternal Care and Services
Indicators Eligible Population Age of Pregnant/Postpartum Women Interpretation
(Col. 3)
10-14 15-19 20-49 Total
(Col. 1) (Col. 2) No. % No. % No. % No. % (Col. 4)
B1. Prenatal Care
1. No. of pregnant women with at least 4 prenatal check-ups - Total
2. No. of pregnant women assessed of their nutritional status during the 1st
trimester - Total
a. Number of pregnant women seen in the first trimester who have normal
BMI - Total
b. No. of pregnant women seen in the first trimester who have low BMI-
Total
c. No. of pregnant women seen in the first trimester who have high BMI-
Total
3. No. of pregnant women for the first time given at least 2 doses of Td
vaccination - Total

4. No. of pregnant women for the 2nd or more times given at least 3 doses of
Td vaccination (Td2 Plus) - Total

5. No. of pregnant women who completed the dose of iron with folic acid
supplementation - Total

6. No. of pregnant women who completed doses of calcium carbonate

supplementation - Total

7. No. of pregnant women given iodine capsules – Total

8. No. of pregnant women given one dose of deworming tablet - Total

9. No. of pregnant women screened for syphilis - Total

10. No. of pregnant women tested positive for syphilis - Total

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11. No. of pregnant women screened for Hepatitis B - Total

12. No. of pregnant women tested positive for Hepatitis B - Total

13. No. of pregnant women screened for HIV - Total

14. No. of pregnant women tested for CBC or Hgb & Hct count - Total

15. No. of pregnant women tested for CBC or Hgb & Hct count diagnosed with
anemia - Total

16. No. of pregnant women screened for gestational diabetes – Total

17. No. of pregnant women tested positive for gestational diabetes – Total

18. No. of teenage pregnancy

Indicators Eligible Population Interpretation
Age of Pregnant/Postpartum Women

(Col. 3)

10-14 15-19 20-49 Total

(Col. 1) (Col. 2) No. % No. % No. % No. % (Col. 4)
B2. Intrapartum Care and Delivery Outcome
19. No. of deliveries – Total

20. No. of live births – Total

21. No. of live births by birth weight - Total

a. No. of live births with normal birth weight - Total

b. No. of live births with low birth weight - Total

c. No. of live births with unknown birth weight - Total

22. No. of deliveries attended by skilled health professionals - Total

a. No. of deliveries attended by a doctor - Total

 b. No. of deliveries attended by a nurse – Total

c. No. of deliveries attended by midwives - Total

23. No. of health facility-based deliveries - Total
24. No. of deliveries by health facility ownership - Total
a. No. of deliveries in public health facility - Total
b. No. of deliveries in private health facility - Total
25. No. of non-facility-based deliveries - Total
26. Type of Delivery
a. No. of vaginal deliveries – Total
b. No. of deliveries by cesarean section – Total
27. Pregnancy Outcome
a. No. of full-term births – Total
b. No. of pre-term births – Total
c. No. of fetal deaths - Total
d. No. of abortion/miscarriage - Total
B3. Postpartum and Newborn Care
28. No. of postpartum women together with their newborn who completed at
least 2 postpartum check-ups - Total
29. No. of postpartum women who completed iron with folic acid
supplementation - Total
30. No. of postpartum women with Vitamin A supplementation – Total
Section C. Child Care and Services
Indicators Eligible Population Counts % Interpretation
(Col.5/E.Po
Male Female Total p x 100)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. Newborns/Infants vaccinated with:
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* CPAB - Total
* BCG - Total
* HepB, within 24 hours. - Total
* DPT-HiB-HepB 1 - Total
* DPT-HiB-HepB 2 - Total
* DPT-HiB-HepB 3 - Total
* OPV 1 - Total
* OPV 2 - Total
* OPV 3 - Total
* IPV - Total
* PCV 1 - Total
* PCV 2 - Total
* PCV 3 - Total
* MCV 1 - Total
* MCV 2 - Total
2. Fully Immunized Child - Total
3. Completely Immunized Child (13-23 months) - Total
4. School-Based Immunization
4.1. Total Grade 1 Learners
- Td, Grade 1 (November) - Total
- MR, Grade 1 (November) - Total
4.1. Total Grade 7 Learners
- Td, Grade 7 (November) - Total
- MR, Grade 7 (November) - Total
C2. Nutrition Services for Infants and Children
5. Newborns initiated on breastfeeding immediately after birth lasting to 90
mins - Total
6. Preterm infants and/or infants with low birth weight (less than 2500 grams) -
Total
6.1. Preterm infants and/or infants with low birth weight given iron
supplementation - Total
7. Infants exclusively breastfed until 6th months - Total

8. Infants 6 mos. old who have initiated and received complementary food with
continued breastfeeding - Total

9. Infants 6 mos. old who have initiated and received complementary feeding
but has stopped breastfeeding or has never been breastfeed at all - Total

Indicators Eligible Population Counts % Interpretation

(Col.5/E.Po
Male Female Total p x 100)

(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)

10. Infants 6-11 mos. given 1 dose of Vit. A 100,000 I.U. - Total

11. Children 12-59 mos. old given 2 doses of Vitamin A 200,000 I.U. - Total

12. Infant 6-11 months old who completed MNP supplementation - Total

13. Children 12-23 months old who completed MNP supplementation - Total

14. Nutritional Status

14.1. Stunted - Total

14.2. Wasted - Total

14.2.a. MAM - Total

14.2.b. SAM - Total

14.3. Overweight and Obese

14.4. Normal - Total

C3. Deworming Services for Infants, Children and Adolescents
1. Children and Adolescents given 2 doses of deworming tablet - Total

a. PSAC, 1-4 years old dewormed (2 doses) - Total

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b. SAC, 5-9 years old dewormed (2 doses) - Total

c. Adolescents, 10-19 years old dewormed (2 doses) - Total

C4. Management of Sick Infants and Children
1. Sick Infants and Children seen - Total
1.1. Sick Infants 6-11 mos. old seen - Total
1.2. Sick Children 12-59 mos. old seen - Total
2. Sick Infants and Children who received Vitamin A - Total
2.1. Sick Infants 6-11 mos. old who received Vitamin A - Total
2.2. Sick Children 12-59 mos. old who received Vitamin A - Total
3. Diarrhea cases 0-59 months old seen - Total
3.1. Diarrheal cases 0-59 months old who received ORS - Total
3.2. Diarrheal cases 0-59 months old who received ORS with oral zinc drops
and syrup - Total
4. Pneumonia cases 0-59 mos. old seen - Total
4.1. Pneumonia cases 0-59 mos. old who completed treatment - Total
Section D. Oral Health Care and Services
Indicators Eligible Population Counts % Interpretation
(Col.5/E.Po
Male Female Total p x 100)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
1. Orally fit children 12-59 months old upon oral examination plus orally fit after
rehabilitation - Total
2. Clients 5 years old and above with cases of DMFT - Total
3. Infants 0-11 months old who received BOHC - Total
4. Children 1-4 years old (12-59 mos.) who received BOHC - Total
5. Children 5-9 years old who received BOHC - Total
6. Adolescents who received BOHC - Total
a. Adolescents 10-14 years old who received BOHC - Total
 b. Adolescents 15-19 years old who received BOHC - Total
7. Adults 20-59 years old who received BOHC - Total
8. Senior citizens 60 years old and above who received BOHC - Total
Indicators Eligible Population Counts Interpretation
10-14 y/o 15-19 y/o 20-49 y/o Total %
(Col.6/ E.Pop x 100)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7) (Col. 8)
9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Services
Indicators Denominator Counts % Interpretation
(Col.5/E.Po
Male Female Total p x 100)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
E1. Filariasis Prevention and Control
1. No. of individual examined for lymphatic filariasis - Total
2. No. of individual examined found positive for lymphatic filariasis - Total

3. No. of lymphatic filariasis cases examined with manifestation of either

lymphedema, hydrocele and elephantiasis - Total
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total
2. No. of suspected cases seen – Total
3. No. of acute clinically diagnosed cases - Total
4. No. of confirmed acute cases - Total
5. No. of chronic clinically diagnosed cases - Total
6. No. of confirmed chronic cases - Total
7. No. of confirmed cases (acute and chronic) - Total
8. No. of cases treated - Total
9. No. of confirmed chronic cases referred to a hospital facility - Total
Indicators Denominator Interpretation
Counts %
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 Indicators 10 Interpretation

(Col.5/E.Po
Male Female Total p x 100)

(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)

E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)

1. No. of WRA, 20-49 years old, who completed 2 doses of deworming tablet -
Total

E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)

E5. Tuberculosis Prevention and Control

1. Number of notified TB cases, all forms - Total

2. Number of registered bacteriologically confirmed drug resistant TB

(RR/MDR-TB Cases) - Total

3. Number of TB, all forms that are cured and completely treated - Total

4. Number of registered bacteriology confirmed drug resistant TB Cases

(RR/MDR-TB) cured and completed treatment - Total

E6. Malaria Prevention and Control

1. No. of patients with probable/clinically diagnosed Malaria and confirmed

case - Total

• < 5 y/o - Total

• ≥ 5 y/o - Total
2. No. of lab-confirmed Malaria deaths - Total

• < 5 y/o - Total

• ≥ 5 y/o - Total
3. No. of confirmed malaria cases in the population - Total

E7. Leprosy Prevention and Control

1. No. of Leprosy cases on treatment during reporting period - Total

2. No. of newly detected cases during reporting period - Total

E8. Rabies Prevention and Control

1. No. of animal bites - Total

2. No. of deaths due to Rabies - Total

Section F. Non-Communicable Disease Prevention and Control Services

Indicators Eligible Population/Denominator Counts % Interpretation
(Col.5/E.Po
Male Female Total p x 100)

(Col. 1)
(Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
Part 1: Lifestyle Related Diseases (Risk-Assessed Using the PhilPEN protocol)

1. No. of adults risk-assessed using PhilPEN - Total

2. Current smokers - Total

3. Alcohol binge drinkers - Total

4. Overweight/Obese-Total

Part 2: Cancer Prevention and Control

1. No. of adult women screened for Cervical Cancer using VIA/Pap Smear -
Total

2. No. of adult women found positive or suspect for Cervical Cancer using
VIA or Pap Smear- Total

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3. No. of adult women screened for breast mass - Total

4. No. of adult women with suspicious breast mass - Total

Part 3: Cardiovascular Disease Prevention and Control

1. No. of newly-identified hypertensive adults - Total

Part 4: Diabetes Mellitus Prevention and Control

1. No. of newly-identified adults with Type 2 Diabetes Mellitus - Total

Part 5: Blindness Prevention Program

1. No. of senior citizens screened for visual acuity - Total

2. No. of senior citizens diagnosed with eye disease/s - Total

3. No. of senior citizens with eye disease/s referred to an appropriate eye care
professional - Total

Part 6: Immunization for Senior Citizens

1. No. of senior citizens who received one (1) dose of PPV - Total

2. No. of senior citizens who received one (1) dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Target/Denominator Total % Interpretation
(Col.5/Target x 100)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. No. of HHs with access to basic safe water supply - Total

a. No. of HHs with Level I - Total

b. No. of HHs with Level II - Total

 c. No. of HHs with Level III - Total

2. No. of HHs using safely managed drinking-water services - Total

3. No of HHs with basic sanitation facility - Total

a. No. of HH with pour/flush toilet connected to septic tank - Total

b. No. of HHs with pour/flush toilet connected to community sewer/sewerage

system or any other approved treatment system - Total

c. No. of HHs with ventilated improved pit latrine (VIP) - Total

4. No. of HHs using safely managed sanitation services - Total

5. No. of industrial establishments issued with sanitary permit - Total

6. No. of food establishments issued with sanitary permit - Total

7. No. of barangays declared ZOD - Total

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Section H. Mortality
Indicators Denominator Counts % Interpretation
Male Female Total
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
1. Total Deaths

2. Maternal Deaths - Total

3. Under-five Deaths - Total

4. Infant Deaths - Total

5. Neonatal Deaths - Total

6. Fetal Deaths - Total

7. Early Neonatal Deaths - Total

8. Perinatal Deaths - Total

Section I. Natality
Indicators Denominator Counts % Interpretation
Male Female Total
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
1. Livebirths - Total

a. Livebirths among 10-14 y/o women - Total

b. Livebirths among 15-19 y/o women - Total

a. Livebirths among 20-49 y/o women - Total

 A1
Services and Deworming for Women of Reproductive Age
RHU
Interpretation Recommendation / Action Taken
(Col. 4) (Col. 5)

CPR Interpretation Recommenda

Col. 6/TP x 25.854% tions/Actions
(Col. 8) to be Taken
20-49 Total (Col. 9) (Col. 10)

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tion B. Maternal Care and Services
Interpretation Recommendations /
Actions to be Taken

(Col. 4) (Col. 5)

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Interpretation Recommendations /
Actions to be Taken

(Col. 4) (Col. 5)
ection C. Child Care and Services
Interpretation Recommendations /
Actions to be Taken

(Col. 7) (Col. 8)

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Interpretation Recommendations /
Actions to be Taken

(Col. 7) (Col. 8)

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on D. Oral Health Care and Services

Interpretation Recommendations /
Actions to be Taken

(Col. 7) (Col. 8)
 Interpretation Recommendations /
Actions to be Taken

(Col. 8) (Col. 9)

tious Disease Prevention and Control Services

Interpretation Recommendations /
Actions to be Taken

(Col. 7) (Col. 8)

Interpretation Recommendations /
Actions to be Taken
23
 Interpretation Recommendations
24 /
Actions to be Taken

(Col. 7) (Col. 8)
are and Maternal Care)
municable Disease Prevention and Control Services
Interpretation Recommendations /
Actions to be Taken

(Col. 7) (Col. 8)

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nvironmental Health and Sanitation Services

Interpretation Recommendations /
Actions to be Taken
(Col. 5) (Col. 6)
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Section H. Mortality
Interpretation Recommendations /
Actions to be Taken
(Col. 7) (Col. 8)

Section I. Natality
Interpretation Recommendations /
Actions to be Taken
(Col. 7) (Col. 8)