Republic of the Philippines

Province of Iloilo
Municipality of San Rafael
Barangay San Florentino

MONTHLY ACCOMPLISHMENT REPORT ON ENVIRONMENTAL HEALTH SERVICES

FOR THE MONTH OF _____________________

WATER QUALITY SURVEILLANCE

I. Inspection of Water Supply

Sources
1.Sampling
1. a. All newly Constructed/ repaired
II. Disinfection of Water supply
sources ( Chlorine )
1. Newly constructed
2.Repaired/ improved
3.Continue disinfection
4. Existing water facilities that is
bacteria
5. Water Bacteriologic ally positive.
III. Household container disinfection.
IV. Food Handlers
VI. Proper Excreta Disposal
1.Inspection of House Hold with
Sanitary Toilet
2.Inspection of House Hold with
Unsanitary Toilet
3.Inspection of House Hold without
Toilet
5.Sanitary Toilet Construction
6.Sanitary Toilet improvement
VI. Insect and Vermin Control
1.Elimination of Breeding Places of
Mosquitoes
2.Inspection of Household Garbage
Disposal

Prepared by: Noted by: Approved by:

__________________ ELYN D. DAMASCO, RM. ___________________________

BHW Sanitation Inspector Primary Health Care Physician
Brgy. San Florentino

BARANGAY HEALTH WORKER MONTHLY ACCOMPLISHMENT REPORT

FOR THE MONTH OF ____________________

I. NUTRITION
1.1st Degree______ III. FAMILY PLANNING
II. IMMUNIZATION
A. BCG A. PILLS_______
1.________ B. IUD________
2.________ C. CONDOM______
3.________ D. BTL_______
E. SDM_______
B. PENTA
1.________ IV. PRENATAL
2.________ A. WITH PRENATAL__________
3.________ B. WITHOUT PRENATAL______

C. POLIO
1.________ V. TOILET
2.________ 1. WATER SEALED:________
3.________ 2. PIT PRIVY:_________

D. HEPA AT BIRTH VI. WATER SUPPLY

1.________ 1.OPEN DUG WELL:______
2.WATER PUMP:_______
E. ROTAVIRUS 3.SPRING:______
1.________
2.________ VII. GARBAGE DISPOSAL
SOLID
F. PCV 1. BURNING________
1.________ 2. COMPOSTING______
2.________ 3. OPEN DUMPLING______
3.________
LIQUID
G. IPV 1. OPEN FIELD ______
1.________ 2. BLIND DRAINAGE_______
3. FEED TO ANIMALS______
H. MEASLES
1.________ VIII. SMOKING
1.YES:______
I.MMR 2.NO:______
1.________
IX. BIRTH:_____M:_____F:_____
F. LAM_______ DEATH_____M:______F:______
G. DMPA_______
H. VASECTOMY_______ X. VEGETABLE GARDEN
YES:
NO:

Prepared by: Noted by:

________________________ ARCELI A. GUMBAN

BARANGAY HEALTH WORKER Midwife III
 Republic of the Philippines
Province of Iloilo
Municipality of San Rafael
Barangay San Florentino
 CERTIFICATION
TO WHOM IT MAY CONCERN:

This is to certify that the following names of persons listed below are active Barangay health workers of
Barangay San Florentino, San Rafael,Iloilo and functional Serving in the community since Jan. to Dec. 2018.

1.MILA B. QUINTO
2.LEDEMA A. LIZA
3.LYN G. CABALLERO
4.EMELYN J. GUTIERREZ
5.LALIN L. SULATORIO
6.ROSALINDA Q. BEDOY
7.MELANIE S. LUNA
8.CONNIE B. PACLIBAR
9.LANI C. TICAR
10.HERMILUNA B. CANINDO
11.MERIAM A. DAYADAY
12.MA.LELIBETH B. GUSTILO
13.HELEN P. DAILAN
14.LORY D. PACARDO
15.REMEBEN B. QUIÑOLA
16.MELANIE P. BAYLON
17.NINFA V. MAGLAPIT

This Certification is issued upon the request of the above names.

Noted:
TERESITA B. FRANCISCO
Municipal BHW Coordinator
ARCELI A. GUMBAN
BHS MIDEWIFE III
 Republic of the Philippines
Province of Iloilo
Municipality of San Rafael
OFFICE OF THE MAYOR

______________________

Date
ITINERARY OF TRAVEL
Name: NINFA V. MAGLAPIT
Position:BHW
Official Station: SAN FLORENTINO,SAN RAFAEL,ILOILO
Purpose of Travel:

Date Place to be Visited Depart.Time Arrival Time Trans. Fare Per Diem TOTAL
11/18/16 Station-Pob. 7:30 am 7:45 am Motorcycle 20:00 160.00 180:00
I Back to Station 4:45 pm 5:00 pm Motorcycle 20:00 20:00

11/21/16 Station-Pob. 7:30 am 7:45 am Motorcycle 20:00 160.00 180:00

Back to Station 4:45 pm 5:00 pm Motorcycle 20:00 20:00

11/22/16 Station-Pob. 7:30 am 7:45 am Motorcycle 20:00 160.00 180:00

Back to Station 4:45 pm 5:00 pm Motorcycle 20:00 20:00

11/23/16 Station-Pob. 7:30 am 7:45 am Motorcycle 20:00 160.00 180:00

Back to Station 4:45 pm 5:00 pm Motorcycle 20:00 20.00

12/4/16 Station-Pob. 10:25 am 10:45 am Motorcycle 20:00 80.00 100.00

Pob. SR.-Banate 11:00 am 11:45 am Motorcycle 60:00 60:00
Banate-Pob.SRI 5:05 pm 5:55 pm Motorcycle 60:00 60:00
Pob.SRI-Station 6:00 pm 6:15 pm Motorcycle 20:00 20:00
320.00 720.00 1,040.00
certify that (1) I have completed
the foregoing itinerary (2) the travel
Is necessary to the service (3) the period Prepared by:
Is reasonable (4) the expenses claimed
are proper.

NINFA V. MAGLAPIT
BHW

APPROVED:

ROBERTO T. BELLEZA JR.

Municipal Mayor
 Republic of the Philippines
Province of Iloilo
MUNICIPALITY OF SAN RAFAEL

ROBERTO T, BELLEZA, JR LGU,SAN RAFAEL

Agency Head Station

MAYOR Date
Designation

I CERTIFY that I have completed the travel authorized in the itinerary of travel no.________________
dated ___________________________, 2015 under the condition below:

________________ xxx Strictly in accordance with the approved itinerary.

_________________________________ Cut short as explained below Excess payment in the amount of
__________________________________ was soon refunded under OR NO.__________________________
dated ______________________________________
__________________________________ Extented as explained below: additional Itenerary Submitted.
__________________________________ Explanation or Justification ______________________________
________ Certificate of Apprearance ______________ Evidence of Travel
attached ______________________________________________________________

Respecfully submitted:

MILA B. QUINTO
BHW

On avidence and information of which I have acknowledge the said travel actually undertaken.

ROBERTO T. BELLEZA JR.

SUPERVISOR
 Republic of the Philippines
Province of Iloilo
Municipality of San Rafael
BARANGAY HEALTH WORKERS/ MONTHLY REPORT
BRGY. SAN FLORENTINO
For the Month of _____________________,2018

IMMUNIZATION TOTAL
BCG

DPT
1
2
3
POLIO
1
2
3
MEASLE
HEPA B
1
2
3
MMR
NO. OF FULLY IMMUNIZED CHILD
1
2
3
4
5
MATERNAL AND CHILD HEALTH PROGRAM
Prenatal
Postnatal Care
NUTRITIONAL STATUS
Ist Degree
2nd Degree
3rd Degree
NORMAL
OVERWEIGHT
FAMILY PLANNING
SWRA
Pills
IUD
BTL
LAM
SDM
 TB PROGRAMS NO OF CASE FINDING
X-RAY
SPUTUM
ENVIRONMENTAL SANITATION
NO.OF HOUSEHOLD
NO. OF POPULATION
WATER SUPPLY
a.Pump Well
b.Douet full
TOILET
a.Sanitary
b.Unsanitary
c.None
ACTIVITIES
NO. OF CHILDREN 6-59 MONTH GIVEN VIT. A
NO. OF CHILDREN 6-59 MONTH GIVEN DEWORMING
GARBAGES DISPOSAL
A. Burning
B.Open Dumping
C.Composting
GARDENING
A.Vegetables
B.Herbal Garden
Noted by: Prepared by:
ROMEO JR. B. DARULLO _____________________________
Kagawad on Health BHW

Approved by:

ARCELI A. GUMBAN
MIDWIFE

Republic of the Philippines

Province of Iloilo
Municipality of San Rafael
BARANGAY HEALTH WORKERS ATTENDANCES SHEET
BRGY. SAN FLORENTINO
NO. NAME AMOUNT SIGNATURE
1 Emelyn J.Gutierez
2 Ledema A.Liza
3 Lyn G.Caballero
4 Rosalinda Q.Bedoy
5 Mila B.Quinto
6 Melanie S.Luna
7 Lalin L.Sulatorio
8 Lelibeth B.Gustilo
9 Meriam A.Dayaday
10 Melanie P.Baylon
11 Connie B.Paclibar
12 Lani C. Ticar
13 Hermilona B.Canindo
14 Helen P. Dailan
15 Lory D.Pacardo
16 Remeben B.Quinola
17 Ninfa V.Maglapit
LANIÑA BALLAO
BHW President

Republic of the Philippines

San Rafael Municipality Health Office
Municipality of San Rafael,Iloilo
 MARTERLIST OF DEWORMING
AGE 13-65 YEARS OLD

BARANGAY:___________________________

NAME BIRTHDAY AGE

 Republic of the Philippines
Province of Iloilo
Municipality of San Rafael
BARANGAY HEALTH WORKER MONTHLY REPORT
BRGY. SAN FLORENTINO
_______________________
Month/Year
TOTAL No. Of Household Covered __________ TOTAL Population Covered____________
 PROGRAM OF ACTIVITIES J F M A M J J A S O N D TOTAL
I. MATERNAL CARE
1.Total No. Of Pregnant Women in the household
area:
2.No.Women referred for Prenatal Care:
Given TT vaccine:
3.No.Women referred to birthing facility ( RHU
-Hospital)
Outcome: Boy
Girl
Alive
Other ( specify)
4.No. of Maternal deaths (during delivery & 42 days after
delivery)
5..No. of Infants deaths ( 0-11 mos.& 29 days)
6.No.of postpartum mothers visited within 4-6weeks
7.No. of postpartum mothers initiated breastfeeding
8.No. Postpartum mothers exclusive breastfeeding in
6mos
9.No. of lactating mothers given Vit.A within 4weeks
10.No.lactating mothers given iron supplementation
II. FAMILY PLANNING
1. No. of postpartum women referred for family planning
2.Total no.of MWRA (15-49 years old)
3.No. of MWRA who are Family Planning Acceptors
Methods: LAM (Lactational Amenorrhea Method)
Pills
Condom
DMPA (injection)
Implant
Tubal Ligation
Vasectomy
III. CHILD CARE
1.No.of newborns reported to RHM within 24 hrs. After
delivery
2.No.of defaulters followed up for immunization
3.no .of children referred for immunization
4.no.of infants o-6 months old
5.no.of o-6 months old infant on exclusive breastfeeding
6.no.of fic for month
7.no.of diarrhea cases referred
IV. NUTRITION
1.OPT:no.of 0-71 month old children weighed
2.BNC.HH profiling (survey form per HH)
3.Initiated household garden-purok
a..HH with backyard garden(vegetable & herbal)
b.Purok with communal garden(vegetable & herbal)
4. Total. Number weighed:
a. o-24 months children weighed quarterly
B. 25-71 months children weighed quarterly
C.o-71 month old children given ECCD cards
5.Assistance in nutrition activities:
A.no.of children feed under feeding program
B.no.of children given deworming drugs
C.no.of children given Vitamin A (6mos-71 month old)
D. Nutrition education conducted (number of times)
D.No.of participants per education conducted
6.Attendance to BNC Meeting
a.Monthly
b.quarterly
7.No. OF household using iodized salt
8.No.of sari-sari store selling iodized salt in HH area
9.No.of vendors selling iodized salt in Market
Submitted by: Noted:

_____________________ ARCELI A. GUMBAN

Name of BHW Signature Rural Health Midwife

VALENTIN B. SULATORIO SAN FLORENTINO BARANGAY HEALTH STATION

Punong Barangay Barangay Health Station

ROMEO B. DARULLO JR.

Brgy. Chairman on Health
Total No. Of Household Covered: Total Population Covered

PROGRAM OF ACTIVITIES Month Total

I. MATERNAL CARE
1.Total No. Of Pregnant Women in the household area:
2.No.Women referred for Prenatal Care:
Given TT vaccine:
3.No.Women referred to birthing facility ( RHU -Hospital)
Outcome: Boy
Girl
Alive
Other ( specify)
4.No. of Maternal deaths (during delivery & 42 days after delivery)
5..No. of Infants deaths ( 0-11 mos.& 29 days)
6.No.of postpartum mothers visited within 4-6weeks
7.No. of postpartum mothers initiated breastfeeding
8.No. Postpartum mothers exclusive breastfeeding in 6mos
9.No. of lactating mothers given Vit.A within 4weeks
10.No.lactating mothers given iron supplementation
II. FAMILY PLANNING
1. No. of postpartum women referred for family planning
2.Total no.of MWRA (15-49 years old)
3.No. of MWRA who are Family Planning Acceptors
Methods: LAM (Lactational Amenorrhea Method)
Pills
Condom
DMPA (injection)
Implant
Tubal Ligation
Vasectomy
III. CHILD CARE
1.No.of newborns reported to RHM within 24 hrs. After delivery
2.No.of defaulters followed up for immunization
3.no .of children referred for immunization
4.no.of infants o-6 months old
5.no.of o-6 months old infant on exclusive breastfeeding
6.no.of fic for month
7.no.of diarrhea cases referred
IV. NUTRITION
1.OPT:no.of 0-71 month old children weighed
2.BNC.HH profiling (survey form per HH)
3.Initiated household garden-purok
 a..HH with backyard garden(vegetable & herbal)
b.Purok with communal garden(vegetable & herbal)

4. Total. Number weighed:

a. o-24 months children weighed quarterly
B. 25-71 months children weighed quarterly
C.o-71 month old children given ECCD cards
5.Assistance in nutrition activities:
A.no.of children feed under feeding program
B.no.of children given deworming drugs
C.no.of children given Vitamin A (6mos-71 month old)
D. Nutrition education conducted (number of times)
D.No.of participants per education conducted
6.Attendance to BNC Meeting
a.Monthly
b.Q uarterly
7.No. OF household using iodized salt
8.No.of sari-sari store selling iodized salt in HH area
9.No.of vendors selling iodized salt in Market
10.Do you promote Iodized Salt (ASIN LAW,RA-8172)
Yes
No.
Number of kilos sold of iodized salt
V.DENTAL CARE
1.No. Of children 12-71 months oldreferred for dental care.
a.With dental care
b.Without dental care
c.Pregnant Women referred
VI.DISEASE CONTROL
1. No. Of TB Symptomatics referred
2.No.of TB cases DOTS supervised (Treatment partner)
3.No.dog bite cases referred
4.No. of suspect diabetes cases referred cases for diagnosis & mgt.
5.No.of cases with eye problem referred
VI.CLINIC CARE
1.No. at times reported & be on duty in a month;
a. BHS
b.RHU
c.Cluster -BHS
2.No. Of patients given first Aid/dressing
3.No. Of health Teachings conducted:
a.No.of participants
b.No. Of patients
4.No. of patients taken
a.Blood pressure /BP
b.Temperature
c.Pulse Rate
d.Weight
d.Others (Specify)
5.No. Of meetings attended:
a.BHS
b.General Assembly
c.Provincial:
a. monthly
b.quarterly
C. Congress
5.No. Of updates attended:
a.Orientation
b.Training/Seminar
Specify title orientation/Training/Seminar attended;

Republic of the Philippines

Province of Iloilo
Municipality of San Rafael
Barangay San Florentino

CERTIFICATION
TO WHOM IT MAY CONCERN:

This is to certify that the following names of persons listed below are active Barangay health workers of
Barangay San Florentino, San Rafael,Iloilo and functional Serving in the community since Jan. to Dec. 2017.

18.MILA B. QUINTO
19.LEDEMA A. LIZA
20.LYN G. CABALLERO
21.EMELYN J. GUTIERREZ
22.LALIN L. SULATORIO
23.ROSALINDA Q. BEDOY
24.MELANIE S. LUNA
25.CONNIE B. PACLIBAR
 26.NIDA T. CASERA
27.HERMILUNA B. CANINDO
28.MERIAM A. DAYADAY
29.MA.LELIBETH B. GUSTILO
30.HELEN P. DAILAN
31.LORY D. PACARDO
32.REMEBEN B. QUINOLA
33.MELANIE P. BAYLON
34.NENFA V. MAGLAPIT

This Certification is issued upon the request of the above names stated.

Noted:
TERESITA B. FRANCISCO
Municipal BHW Coordinator
ARCELI A. GUMBAN
BHS MIDEWIFE III

Republic of the Philippines

Province of Iloilo
Municipality of San Rafael
Barangay San Florentino

CERTIFICATION
TO WHOM IT MAY CONCERN:

This is to certify that the following Barangay health workers are active and functional since January to
December 2016
1.MILA B. QUINTO
2.LEDEMA A. LIZA
3.LYN G. CABALLERO
4.EMELYN J. GUTIERREZ
5.LALIN L. SULATORIO
6.ROSALINDA Q. BEDOY
7.MELANIE S. LUNA
8.CONNIE B. PACLIBAR
9.NIDA T. CASERA
10.HERMILUNA B. CANINDO
11.MERIAM A. DAYADAY
12.MA.LELIBETH B. GUSTILO
13.HELEN P. DAILAN
14.LORY D. PACARDO
15.REMEBEN B. QUINOLA
16.MELANIE P. BAYLON
17.NINFA V. MAGLAPIT

This Certification is issued upon the request of the above names stated.

ARCELI A. GUMBAN
MIDEWIFE III
SAN FLORENTINO BHS

1.MILA B. QUINTO
2.LEDEMA A. LIZA
3.LYN G. CABALLERO
4.EMELYN J. GUTIERREZ
5.LALIN L. SULATORIO
6.ROSALINDA Q. BEDOY
7.MELANIE S. LUNA
8.CONNIE B. PACLIBAR
9.NIDA T. CASERA
10.HERMILUNA B. CANINDO
11.MERIAM A. DAYADAY
12.MA.LELIBETH B. GUSTILO
13.HELEN P. DAILAN
14.LORY D. PACARDO
15.REMEBEN B. QUINOLA
16.MELANIE P. BAYLON
17.NINFA V. MAGLAPIT

BARANGAY SAN FLORENTINO

UNSANITARY
1. Emilio Alcampor
2. Erene Causing
3. Romel Berlanas
4. Joel Causing
5. Ronie Berlanas
6. Arjay Balajadia
7. Ronie Blaza
8. Edgardo Pendella
9. Lito Lagatoc
10. Heddie Artagame
11. Lelia Garbino
12. Hermie Artagame
13. Jesus Bedoy
14. Johnny Gallego
15. Henden Bedoy
16. Fredde Garcia
17. Emmanuel Jamosin
18. Welmie Caballero
19. Victoria Darullo
20. Allan Bahian
21. Glen Liza
22. Salvacion Laman
23. Fe Deferia
24. Marklyn Sencir
25. Marjohn Dayaday
26. Clarisa Pajadora
27. Feljun Fuentes
28. Raymond Lañada
29. Alicia Sulatorio
30. Dodo Loredo
31. Ely Baylon
32. Jerry Sulatorio
33. Jay Gutierrez
34. Lony Alcampor
35. Rosebert Berlanas
36. Solidad Gutierrez
37. Melodeno Paclibar
38. Arth Paclibar
39. Nathanniel Aranque
40. Leopoldo Lara
41. Lelia Catunao
42. Jose Ganzon Sr.
43. Jimmy Ganzon
44. Orlando Ticar
45. Cris Ticar
46. Ralph Salaya
47. Ronnel Tanaleon
48. Rolfen Casera
49. Garry Gabaldon
50. Rogelio Casera

51. Alberto Gabaldon

52. Adelino Ariego Jr.
53. Jovel Bañes
54. Eledenio Dago-o
55. Ben Dailan
56. Jansen Umadhay
57. Nereta Canindo
58. Nestor Blancaflor
59. Ali Paclibar
60. Rodel Redubla
61. Jose Ganzon Jr.
62. Reynaldo Ticar
63. Jolly Ticar
64. Joenel Ticar
65. Crisostomo Palencia
66. Ednel Gabaldon
67. Noli Gabaldon
68. Jose Jongco Jr.
69. Jorry Salaya
70. Vergenia Salaya
71. Nemesio Salaya
72. George Panes
73. Ramy Salaya
74. Jovelino Tedios
75. Saul Ticar
76. Jomarie Dago-oc
77. Joey Dago-oc
78. Ian Querido
79. Cris Paclibar
80. Rutcy Dago-oc
81. Jimmy Paclibar
82. Richard Dailan
83. Richie Dailan
84. Hermoso Dailan Jr.
85. Randy Borbe
86. Jimmy Pacardo
87. Allan Espago
88. Christopher Lara
89. Rogelio Paderes
90. Remart Paclibar
91. Alven Pacardo
92. Jose Heron Juntado
93. Ronel Paderes
94. Wennie Pacardo
95. Lowelyn Gerao
96. Ernesto Pacardo
97. Teresita Pacardo
98. Noredel Padura
99. Evy Pacardo
100. Kenneth Paladin
101. Rio Darullo
102. Joel Palencia
103. Belleo Palencia

104. Allan Joy Pacardo

105. Johnrey Pacardo
106. Johnny Pacardo
107. Elpedio Pacardo
108. Jeffrey Balayo
109. Aaron Ocampo
110. Jolex Aguilar
111. Romy Cosio
112. Gerald Pachica
113. El Balayo
114. Porferio Condedesimo
115. Jemmy Darullo
116. Clareta Quinoviva
117. Rolyn Fuentes
118. Junrey Villa
119. Jesus Trespecios
120. Lexter Trespecios
121. Harry Doloiras
122. Jerry Palmares Sr.
123. Jerry Palmares Jr.
124. Taciana Trespecios
125. Marlon Fernandez
126. Raffy Delapeña
127. Lamberto Berdandino
128. Ramon Pascual
129. Silvino Lañada Jr.
130. Julyn Lañada
131. Welma Lañada
132. Danny Casa
133. Jessie Libo-on
134. Jesie Legario
135. Dany Calderon
136. Marlon Fernandez
137. Rell Paderes
138. Herman Fuentes
139. Robert Camarenes
140. Ernesto Pahayahay
141. Rj Lañada
142. Gelda Pamotillo
143. Ignacio Barber Jr.
144. Nyhell Barber Sr.
145. Ignacio Barber Sr.
146. Morito Baleña
147. Melmer Alcampor
148. Reynaldo Lañada
149. Temoteo Lañada
150. Lelibeth Lañada
151. Flovenio Gabais
152. Lynie Lañada
153. Marcelino Pamposa
154. Evie Barber
155. Renan Pamotillo
156. Melanio Lañada

SHARED

1. Ronald Gregorio
2. Juvert Jan Gellado
3. Selman Balenia
4. Lona May Bamo
5. Jerome Celleros
6. Glea Labos
7. Hary Alcampor
8. Ronald Juanico
9. John Louie Balenia
Prepared By: Approved by:

MILA B. QUINTO VALENTIN B. SULATORIO

BHW President Punong Barangay