Pantawid Pamilya (4Ps) Responsible Parenthood-Family Planning Class Report Form 1

Non-Pantawid Pamilya (Non-4Ps) Cluster/Group No:

Faith-Based Organization Date Conducted: Year Mon Day Encode By (Email):
PMC Name of Municipal Link: Location Ref:
Usapan Serye Name of Parent Leader: RP-FP Class No.
Others, pls specify: _______________

PROFILE Modern FP User Non-Modern FP User REFERENCE CODES

PARTICIPANT'S
Name of Participant/Couple Reason for SIGNATURE
Highest PhilHealth Reason for Civil Status (Column 3)
Sex Civil member? No. of Method Intending to 1 - Married
Birthdate (dd/mm/yyyy) Address/HH ID Number Occupation Educational Using FP Type Status
(M/F) Status Attainment (pls check) Children Used use FP 2 - Single
Method 3 - Widow/Widower
Yes No Method
4 - Separated
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) 5 - Live-in
Occupation (Column 6)
1 1 - Gov't Employee
2 - Private Employee 6 - Laborer
3 - Farmer 7 - Vendor
4 - Fisherfolk 8 - Other Occupation
5 - Housekeeper 9 - None

2
Highest Educational Attainment (Column 7)
1 - No Education 6 - Vocational
2 - Elementary Level 7 - College Level
3 - Elementary Graduate 8 - College Graduate
4 - High School Level 9 - Post Graduate
3 5 - High School Graduate

Modern FP Method Used (Column 10)

Artificial Methods Modern NFP Methods
1 - Condom 8 - CMM/Billings
4 2 - IUD 9 - BBT
3 - Pills 10 - Sympto-Thermal
4 - Injectable 11 - SDM
5 - Vasectomy 12 - LAM
6 - Tubal Ligation
7 - Implant
5

Reason for Using FP Method/Intending To Use

(Cols. 11 & 14)
1 - Spacing
2 - Limiting
6 3 - Achieving

Non-Modern FP User : TYPE (Column 12)

Traditional FP User Non-FP User
01 - Withdrawal 06 - No Method
02 - Rhythm
7 03 - Calendar
04 - Abstinence
05 - Herbal

Non-Modern FP User : STATUS (Column 13)

8 A -Expressing Intention to Use Modern FP Method
(indicate Code for Modern FP Methods used in Col. 10)
B - Undecided
C - Currently Pregnant
D - No Intention to Use

10

Prepared by: Reviewed by: Approved by:

__________________________________ __________________________________ _______________________________________________

Name/Signature of RPM Team Member Name and Signature of Municipal/City Link Name and Signature of Provincial/City Population Officer
 6 - Laborer
7 - Vendor
8 - Other Occupation
9 - None

Highest Educational Attainment (Column 7)

1 - No Education 6 - Vocational
2 - Elementary Level 7 - College Level
3 - Elementary Graduate 8 - College Graduate
4 - High School Level 9 - Post Graduate
5 - High School Graduate

Modern NFP Methods

8 - CMM/Billings
9 - BBT
10 - Sympto-Thermal
11 - SDM
12 - LAM

Reason for Using FP Method/Intending To Use

(Cols. 11 & 14)
1 - Spacing
2 - Limiting
3 - Achieving

Non-Modern FP User : STATUS (Column 13)

A -Expressing Intention to Use Modern FP Method
(indicate Code for Modern FP Methods used in Col. 10)
B - Undecided
C - Currently Pregnant
D - No Intention to Use