0% found this document useful (0 votes)
14 views3 pages

The Space Provided.: Luzonhealth

This document is a monitoring tool used to track the availability and stockouts of family planning and maternal, neonatal, child health, and nutrition (MNCHN) commodities at health facilities over the past 3 months. It collects information on whether various commodities are available or have been out of stock, the usual source of procurement, and the amount of local government unit funds used to purchase FP and MNCHN commodities from 2013 to present. Signatures are required to certify the accuracy of the reported information.

Uploaded by

azuredream
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
14 views3 pages

The Space Provided.: Luzonhealth

This document is a monitoring tool used to track the availability and stockouts of family planning and maternal, neonatal, child health, and nutrition (MNCHN) commodities at health facilities over the past 3 months. It collects information on whether various commodities are available or have been out of stock, the usual source of procurement, and the amount of local government unit funds used to purchase FP and MNCHN commodities from 2013 to present. Signatures are required to certify the accuracy of the reported information.

Uploaded by

azuredream
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

Form 5 Monitoring tool for FP/MNCHN Commodity Availability and Stock Out

LuzonHealth
Integrated Maternal, Neonatal, Child Health and Nutrition/Family Planning Regional Project in Luzon

General Instructions: Please encircle the corres onding ans!ers or indicate your res onse in the s ace ro"ided# A. MNCHN/FP Commodity Availability and toc!"out
Column # A_.1 Are the following MNCHN/FP commodities/instruments available in this facilit as of today! "f YES, go to Column 2, otherwise proceed to Column 3. Column $ A_.# $id ou e%&erience stoc'(out of these commodities/ instruments in the past three months! $ %es $ %es $ %es $ %es $ %es $ %es $ %es $ %es $ %es $ %es & No & No & No & No & No & No & No & No & No & No Column % A_.) *hat is the usual source of this commodit !
1=Procured y !"# 2=$onated 3=%oth 1 & 2 '=(thers

$# Pills &# Injecta)les *+MP,'# Condom (# I.+ /# Iron !ith 0olic acid 1# 2itamin , 0or lactating mothers 3# 2itamin , 0or 4P 5# 2itamin , 0or sic6 children 7# Re0ormulated 8R9 $:# ;inc +dis&ersable tablet, dro&s/s ru&$$# ,nti)iotics 0or children !ith Pneumonia $&# <PI "accines

$ %es $ %es $ %es $ %es $ %es $ %es $ %es $ %es $ %es $ %es

& No & No & No & No & No & No & No & No & No & No

$ $ $ $ $ $ $ $ $ $

& & & & & & & & & &

' ' ' ' ' ' ' ' ' '

( ( ( ( ( ( ( ( ( (

$ %es

& No

$ %es

& No

&

'

$ %es $ %es

& No & No

$ %es $ %es

& No & No

$ $

& &

' '

( (

$'# ,)sor)ent Filter Card *0or N=9- *F8R N=9>certi0ied 0acility only$(# 9terile 4lo"es

$ %es $ %es

& No & No

$ %es $ %es

& No & No

$ $

& &

' '

( (

$/# +is osa)le sterile syringes and needles

Form 5 Monitoring tool for FP/MNCHN Commodity Availability and Stock Out

$1# +isin0ectant solution *e#g# chlorine$3# Container 0or shar s $5# =ag 0or trash segregation

$ %es

& No

$ %es

& No

&

'

$ %es $ %es

& No & No

$ %es $ %es

& No & No

$ $

& &

' '

( (

)S* (+!Y if the ,)C-!-.Y is a irthing facility or has a %/S that is a irthing facility, (therwise, +o need to as0 these 1uestions. $7# 8?ytocin $: I. &:# +e?amethasone IM &$# Magnesium sul hate /g &&# +iaze am * arenteral- $: mg &'# Calcium gluconate $g $ %es $ %es $ %es $ %es $ %es & No & No & No & No & No $ %es $ %es $ %es $ %es $ %es & No & No & No & No & No $ $ $ $ $ & & & & & ' ' ' ' ' ( ( ( ( (

,(2 City /ealth (ffice )+$ 2ural /ealth #nit34/C (+!Y &. LG' Commodity el( )eliance Ho! much !as used to *rocure FP commodities and MNCHN commodities using !"# funds in 2513 to present@ FP Commodities FP/MNCHN Commodities )+MA), $-#. /As o( $-#. /As o( $-#% $-#% March0 March0 Aotal amount o0 L4. 0unds used to #1.2 -#. 342 --#1.2-#. / #32 116 rocure 512556.43
&

Form 5 Monitoring tool for FP/MNCHN Commodity Availability and Stock Out commodities +(.E. Attach means of verification +M/0- for commodit &rocurement such as deliver recei&t, &urchase order, A/P with budget line item for FP commodities and MNCHN commodities, etc.

7his is to certi(y that the in(ormation *rovided are true and correct8

Flordeliza Manalaysay2 )N2 MAN Public Health Nurse

Michael An9elo A. )aymundo2 M: Munici*al Health ;((icer

A*ril #-2 $-#. :ate i9ned

A*ril #-2 $-#. :ate i9ned

Accom*lished by8 9ignature o"er rinted name Position +ate:

Flordeliza Manalaysay2 )N2 MAN Nurse I< A*ril #-2 $-#.

'

You might also like