Department of Health

Barangay Health Worker Registration Form

A. IDENTIFICATION
1. REGION _______________________________________
2. PROVINCE _______________________________________
3. MUNICIPALITY / CITY _______________________________________
4. BARANGAY _______________________________________
5. REGISTRATION NO. _______________________________________ 2X2 PICTURE
6. DATE OF REGISTRATION _______________________________________
7. PLACE OF REGISTRATION _______________________________________
8. ACCREDITATION NO. _______________________________________
9. DATE OF ACCREDITATION _______________________________________
10. PLACE OF ACCREDITATION _______________________________________
B. BHW PROFILE
___________________________________________________________________________________________
1. NAME OF BHW _____________________ _____________________ ____________________
LAST NAME FIRST NAME MIDDLE NAME

2. COMPLETE ADDRESS ____________________________________________________________________

PUROK BARANGAY MUNICIPALITY / CITY PROVINCE

3. DATE OF BIRTH B.4 AGE ON REGIS.

MALE FEMALE B.6 CIVIL STATUS

5. SEX
SINGLE WIDOWED

MARRIED SEPARATED
B7. DEPENDENTS
No. NAME Relationship of BHW Date of Birth
1 1 2 3 4 5 6 Month Day Year
2
3
4
5
6

1-SON 2-DAUGHTER 3-GRANDCHILD 4-NIECE/NEPHEW 5-ADOPTED/FOSTER CHILD 6-OTHERS, PLEASE SPECIFY

C. SERVICE RECORDS
C1. INCLUSIVE DATES C2. STATION / PLACE OF ASSIGNMENT
FROM TO
MONTH DAY YEAR MONTH DAY YEAR ___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

C3. Number of households presently covered.

C4. Is your present place of assignment considered hazardous area? YES NO

C5. Technical Supervisor Name: __________________________ Position: ____________________

Agency/Office: _________________

D1. TITLE OF TRAINING D2. DATE D3. CONDUCTED BY

E1. HIGHEST EDUCATION ATTAINMENT ______________________________________________________________

E2. BLOOD TYPE B AB O

A

E3. BHW WITH KIT WITHOUT KIT

Date Accomplished: _______________________________