PBSP Program Officer and Regional Technical Staff copy furnish your Team Leader. Failure to
comply may result in disciplinary action.***
Label your report as (facility code_facility name_drtb registered cases_as of date accomplished)
e.g. 03 LCP TC drtb registered cases as of 020519
7. Columns 6th Month Interim Outcome, Status/Final Outcome, Reason (if outcome is LTFU), date of
outcome and remarks should be updated regularly whenever there is a change in patient's treatment
status.
Facility Name and Code: 03 Lung Center of the Philippines
LPA Tested Jan-Jun 2018 Percentage Jul-Dec 2018 Percentage Jan-Jun 2019
TOTAL 0 0 0
Yes 0 #DIV/0! 0 #DIV/0! 0
No 0 #DIV/0! 0 #DIV/0! 0
6th Month Interim Outcome Jan-Jun 2018 Percentage Jul-Dec 2018 Percentage Jan-Jun 2019
TOTAL 0 0 0
Negative 0 #DIV/0! 0 #DIV/0! 0
Positive 0 #DIV/0! 0 #DIV/0! 0
Not Evaluated 0 #DIV/0! 0 #DIV/0! 0
Failed 0 #DIV/0! 0 #DIV/0! 0
Died 0 #DIV/0! 0 #DIV/0! 0
Lost to Follow-up 0 #DIV/0! 0 #DIV/0! 0
Pending 0 #DIV/0! 0 #DIV/0! 0
Final Treatment Outcome Jan-Jun 2018 Percentage Jul-Dec 2018 Percentage Jan-Jun 2019
TOTAL 0 0 0
Cured 0 #DIV/0! 0 #DIV/0! 0
Treatment Completed 0 #DIV/0! 0 #DIV/0! 0
Died 0 #DIV/0! 0 #DIV/0! 0
Ongoing 0 #DIV/0! 0 #DIV/0! 0
Lost to Follow-up 0 #DIV/0! 0 #DIV/0! 0
Trans-out 0 #DIV/0! 0 #DIV/0! 0
Treatment Failed 0 #DIV/0! 0 #DIV/0! 0
Withdrawn 0 #DIV/0! 0 #DIV/0! 0
Excluded 0 #DIV/0! 0 #DIV/0! 0
Reason for LTFU Jan-Jun 2018 Percentage Jul-Dec 2018 Percentage Jan-Jun 2019
TOTAL 0 0 0
ADRs 0 #DIV/0! 0 #DIV/0! 0
Bedridden / Immobility due to other 0 #DIV/0! 0 #DIV/0! 0
disease
Co-morbidities 0 #DIV/0! 0 #DIV/0! 0
Died 0 #DIV/0! 0 #DIV/0! 0
Family-related issues 0 #DIV/0! 0 #DIV/0! 0
Far distance to S/TC or iDOTS 0 #DIV/0! 0 #DIV/0! 0
Financial problems 0 #DIV/0! 0 #DIV/0! 0
Intentional hiding 0 #DIV/0! 0 #DIV/0! 0
Old Age 0 #DIV/0! 0 #DIV/0! 0
Preferred Other Healers/Spiritual 0 #DIV/0! 0 #DIV/0! 0
Belief/Religious Belief
Preferred Private MD 0 #DIV/0! 0 #DIV/0! 0
Pregnancy / Miscarriage 0 #DIV/0! 0 #DIV/0! 0
Privacy Issues 0 #DIV/0! 0 #DIV/0! 0
Personal 0 #DIV/0! 0 #DIV/0! 0
Relocated to Other Place/Wrong 0 #DIV/0! 0 #DIV/0! 0
Address
S/TC or iDOTS staff related-issues 0 #DIV/0! 0 #DIV/0! 0
Substance abuse 0 #DIV/0! 0 #DIV/0! 0
Work/School conflict 0 #DIV/0! 0 #DIV/0! 0
Wrong/No Contact Number 0 #DIV/0! 0 #DIV/0! 0
Percentage Jul-Dec 2019 Percentage
0
#DIV/0! 0 #DIV/0!
#DIV/0! 0 #DIV/0!
1
2
3
4
5
Reason if not Treatment Complete Address Contact Number
tested for LPA Regimen
Reason (if 6th Month
6th Month Interim Status / Final
Interim Outcome is NOT
Outcome Outcome
DONE)
Reason (if outcome is LTFU) Date of Outcome
Remarks / Reason (if outcome is DIED and
specify if reason for LTFU is ADR)
Facility Name and Code: 03 Lung Center of the Philippines
1
2
3
4
5
Reason if not Treatment Complete Address Contact Number
tested for LPA Regimen
Reason (if 6th Month
6th Month Interim Interim Outcome is NOT Status / Outcome
Outcome DONE)
Reason (if outcome is LTFU) Date of Outcome
Remarks / Reason (if outcome is DIED and
specify if reason for LTFU is ADR)
Facility Name and Code: 03 Lung Center of the Philippines
1
2
3
4
5
Reason if not Treatment Complete Address Contact Number
tested for LPA Regimen
Reason (if 6th Month
6th Month Interim Interim Outcome is NOT Status / Outcome
Outcome DONE)
Reason (if outcome is LTFU) Date of Outcome
Remarks / Reason (if outcome is DIED and
specify if reason for LTFU is ADR)
Facility Name and Code: 03 Lung Center of the Philippines
1
2
3
4
5
Reason if not Treatment Complete Address Contact Number
tested for LPA Regimen
Reason (if 6th Month
6th Month Interim Interim Outcome is NOT Status / Outcome
Outcome DONE)
Reason (if outcome is LTFU) Date of Outcome
Remarks / Reason (if outcome is DIED and
specify if reason for LTFU is ADR)