The Space Provided.: Luzonhealth
The Space Provided.: Luzonhealth
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
$ $
& &
' '
( (
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
'