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RBIM Standard Tool Final Tool 2022 6

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25 views1 page

RBIM Standard Tool Final Tool 2022 6

Uploaded by

ar25collamat
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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6 7

A. DEMOGRAPHIC CHARACTERISTICS C. HEALTH INFORMATION D. SOCIO-CIVIC PARTICIPATION E. MIGRATION INFORMATION


FOR 10 & FOR 60 & FOR 15 &
FOR ALL HOUSEHOLD MEMBERS FOR ALL HOUSEHOLD MEMBERS FOR ALL HOUSEHOLD MEMBERS
ABOVE ABOVE ABOVE
Q27 Q28
Q31 Q35
Q26 FACILITY REASON Q32 Q36
Q1 Q3 Q4 Q29 Q30 REGISTERED Q33, Q34 LENGTH OF
HEALTH VISITED IN FOR VISIT REGISTERED TYPE OF
NAME SEX AGE DISABILITY SOLO PARENT SENIOR PREVIOUS RESIDENCE STAY IN THE
INSURANCE PAST 12 IN HEALTH VOTER RESIDENT
CITIZEN BARANGAY
MONTHS FACILITY
Copy from previous response What is the What facility What is the Is there a Is there a Is __ a In what In what In what How long is __ <Do not ask>
primary health did __ visited reason for member of the member of the registered barangay is barangay and barangay and been staying in
insurance __ in the past 12 the visit in HH that has any HH that is a solo senior citizen? __ a city/ city/municipality this barangay? Indicate if
LINE have? months? health disability? What parent? Is he/ registered municipality did did __ reside six Non-migrant,
LIST facility? is the disability? she registered? voter? __ reside five months ago? No. of years/ Migrant or
NO. years ago? No. of months Transient

10

Q26 Health Insurance Q27 Facility Visited Q28 Reason for Visit Q29 Disability NOTES: Q35 Length of Stay Q36 Type of Resident
PhilHealth paying member = 1 Government hospital = 1 Sick/Injured = 1 Psychosocial Disability = 1 For Q31—If 0 to 59 years old, write 99 in Barangay Non-Migrant = 1
PhilHealth dependent of paying RHU/Health center = 2 Prenatal/Postnatal = 2 Chronic Illness = 2 For Q32—If 0 to 14 years old, write 99 Write the number (Response in Q33 and Q34 is the same
member = 2 Brgy. Health Station = 3 Gave birth = 3 Learning Disability = 3 of years and with current residence)
PhilHealth indigent member = 3 Private hospital = 4 Dental = 4 Mental Disability = 4 months of stay in Migrant = 2
PhilHealth dependent of Private clinic = 5 Medical check-up = 5 Visual Disability = 5 Q31 Registered Senior Citizen Q33 Previous Residence the barangay. (Response in Q33 and/or Q34 is different
indigent member = 4 Pharmacy = 6 Medical requirement = 6 Orthopedic Disability = 6 Yes = 1 Write the barangay and city/ Write the year in with current residence and response in
GSIS = 5 Hilot/Herbalist = 7 NHTS/CCT/4Ps requirement = 7 Hearing Disability = 7 No = 2 municipality where household the upper triangle Q35 is at least six months and one day)
SSS = 6 If other facility, If other reason, write the response Speech Impairment = 8 member resided five years ago and the month in Transient = 3
Private/HMO = 7 write the response Multiple Disabilities = 9 Q32 Registered Voter the lower triangle. (Response in Q33 and/or Q34 is different
If others, please write the Q30 Solo Parent Not Applicable = 99 Please write the name of the Q34 Previous Residence with current residence and response in
NOTE: For Q30
response Registered Solo parent = 1 barangay in which HH member Write the barangay and city/ Q35 is less than six months)
If 0 to 9 years old, write 99 Non-Solo Parent = 2 municipality where household
is registered as voter.
Unregistered Solo Parent = 3 member resided six months ago

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