Month ______________ 19 ____
Name of PF clinic _____________________________________________
Clinic code number: _____________________
Name of subdistrict: _____________________________________________
Subdistrict code: _____________________
Clinic status:
I. Service frequency:
II. Service outputs
| New Acceptor (Persons) | Contraceptive Method Switches (Persons) | |||
| Contraceptive Method | FP Clinic Hospital | Mobile FP Team | Total | FP Clinic/Hospital Mobile Team/FP Program |
1 2 | 3 | 4 | 5 | 6 |
| 1. IUD | ||||
| 2. Pill | ||||
| 3. Condom | ||||
| 4. Vaginal tablet | ||||
| 5. Male Sterilization | ||||
| 6. Female Sterilization | ||||
| 7. Injectable | ||||
| 8. Implant | ||||
| TOTAL | ||||
III.Contraceptive Distribution (Initial and Resupply)
| Contraceptives dispensed to Acceptors (Initial and Resupply) | ||||
| Contraceptive Method | FP Clinic Hospital | Mobile Family Planning Team | VCDC* | TOTAL |
1 2 | 3 | 4 | 5 | 6 |
| 1. Pill (cycles) | ||||
| 2. Condoms (dozen) | ||||
| 3. Vaginal tablet (tube) | ||||
| 4. Injectable (flagon) | ||||
| 5. Implant (unit) | ||||
Note: This monthly report should be sent to Central BKKBN no later than the fifth fday after the reporting month.
*VCDC - Village Community Distribution Center
IV. Counseling, Side Effects/Complications and Failure
| Counseling | Side effects/complications | ||||||||||
| Contraceptive method | Potential user | Continuing user | Minor | Major | Total | Failure | |||||
1 2 |
3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 |
| 1. Sterilization/M | |||||||||||
| 2. Sterilization/F | |||||||||||
| 3. IUD | |||||||||||
| 4. Injectable | |||||||||||
| 5. Implant | |||||||||||
| TOTAL | |||||||||||
A = Unreversible
B = Reversible
V. Contraceptive Service Outlets
| FP Clinic | Balance at VCDC before taken to clinic | ||
| Contraceptive method | Dispensed this month | Stock at the end of the month | |
1 2 | 3 | 4 | 5 |
| 1. IUD | |||
| 2. Pill (cycles) | |||
| 3. Condoms (dozen) | |||
| 4. Injectable (flagon) | |||
| 5. Implant (unit) | |||
VI. Remarks: _____________________________________________________________________
__________________________________________________________________________________
Clinic officer in charge: __________________________________________________