Republic of the Philippines
Department of Health
EPIDEMIOLOGY BUREAU
LABORATORY AND BLOOD BANK SURVEILLANCE (LaBBS)
Reporting Form 1
Name of Facility: VIRGEN MILAGROSA MEDICAL CENTER Facility Ownership: Government Facility Type: Hospital Maternal/ Antenatal Clinic
Mun/City: SAN CARLOS (Check one) Private Laboratory Treatment Hub
Province: PANGASINAN TB-DOTS Clinic Social Hygiene Clinic
Year: Jul-05
HIV HEPATITIS B HEPATITIS C
Number of HIV screening tests Number of non-reactive HIV Number of non-reactive results Number of screening tests Number of HIV confirmatory Number of Hepatitis B screening Number of reactive/positive for Number of Hepatitis C screening Number of reactive/positive for
Month done screening tests released to client reactive to HIV results released to client tests done Hepatitis B tests done Hepatitis C
Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant*
January 20 0 0 20 0 0 0 0 0 0 0 0 0 0 0 20 0 18 0 0 0 14 0 0 0 0 0
February 41 0 0 4 0 0 0 0 0 0 0 0 0 0 0 20 4 20 0 0 0 29 0 0 0 0 0
March 44 1 0 44 1 0 0 0 0 0 0 0 0 0 0 44 1 11 0 1 1 44 1 0 0 0 0
April
42 3 0 42 3 0 0 0 0 0 0 0 0 0 0 43 3 12 0 0 0 42 0 0 0 0 0
May
June
July
August
September
October
November
December
*Of females, number of pregnant (if data available) 1 of 2
Please submit your report to your respective DOH Regional Office (RO) on the 1st week of the succeeding month
Revised as of October 2016
Republic of the Philippines
Department of Health
EPIDEMIOLOGY BUREAU
LABORATORY AND BLOOD BANK SURVEILLANCE (LaBBS)
Reporting Form 1
SYPHILIS GONORRHEA
Number of smears (urethral, Number of smears with
Month Number of Syphilis screening Number of tests reactive (RPR, Number of confirmatory tests for Number of TPPA/TPHA tests Number of smears with
cervical & rectal) screened for intracellular and extracellular
(RPR, ICT, etc.) tests done ICT, etc.) for Syphilis Syphilis done positive for Syphilis intracellular diplococci
Gonorrhea diplococci
Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant* Male Female Pregnant*
January 20 0 4 0 0 0
February 20 0 9 0 0 0
March
40 0 3 0 0 0
April
35 0 10 0 0 0
May
June
July
August
September
October
November
December
*Of females, number of pregnant (if data available) 2 of 2
Please submit your report to your respective DOH Regional Office (RO) on the 1st week of the succeeding month
Revised as of October 2016
Prepared by:
Name:
Designation:
Contact Number:
Republic of the Philippines
Department of Health
EPIDEMIOLOGY BUREAU
LABORATORY AND BLOOD BANK SURVEILLANCE (LaBBS)
Reporting Form 2
Name of Facility: Facility Ownership: Government Facility Type: Hospital Laboratory
Mun/City: (Check one) Private Clinic Laboratory
Province: Stand-alone Laboratory
Philippine Red Cross
Philippine Blood Center
Year:
HIV HEPATITIS B HEPATITIS C SYPHILIS
Number of Blood Units Number of Blood Units Number of Blood Units Number of Blood Units Number of Blood Units Number of Blood Units Number of Blood Units Number of Blood Units
Month Screened for HIV Reactive to Anti-HIV Screened for Hepatitis B Reactive to Hepatitis B Screened for Hepatitis C Reactive to Hepatitis C Screened for Syphilis Reactive to Syphilis
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
January
February
March
April
May
June
July
August
September
October
November
December
Please submit your report to your respective DOH Regional Office (RO) on the 1st week of the succeeding month
Revised as of October 2016
Prepared by: ___________________________________________________________________________
Name: ___________________________________________________________________________
Designation: ___________________________________________________________________________
Contact Number: ___________________________________________________________________________
