BADAC-DCF-UBRA-CIR.xlsx

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2		BADAC DATA CAPTURE FORM 4
3		UNIFIED BARANGAY REPORT ON REFERRAL ACTION (UBRRA)
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5	Data provided herein are those recorded within the months of: January to June ( ) July to December ( )										Year (YYYY): __________________________
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7	INDICATOR		NO. OF SURRENDERERS					INDICATOR		NO. OF REFERRED SURRENDERERS
8			MALE		FEMALE		TOTAL			MALE		FEMALE		TOTAL
9			BELOW 18	ABOVE 18	BELOW 18	ABOVE 18	TOTAL			BELOW 18	ABOVE 18	BELOW 18	ABOVE 18	TOTAL
10	Submission of Updated Number of Residents who Surrenderred							Submission of Updated Number of Referred Surrenderers
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16	INDICATOR	STATUS / LEVEL OF RISK	STATUS AND NO. OF ASSESSED SURRENDERERS					INDICATOR	WELLNESS & RECOVERY INTERVENTIONS	NO. OF SURRENDERERS ENROLLED IN WELLNESS & RECOVERY INTERVENTIONS
17			MALE		FEMALE		TOTAL			MALE		FEMALE		TOTAL
18			BELOW 18	ABOVE 18	BELOW 18	ABOVE 18	TOTAL			BELOW 18	ABOVE 18	BELOW 18	ABOVE 18	TOTAL
19	Submission of Updated Number of Assessed Surrenderers	Low						Submission of Updated Number of Enrolled Surrenderers	General Interventions
20		Mild							Community-based Treatment & Rehab
21		Moderate							Health Facility-based Outpatient Treatment & Rehab
22		Severe							Inpatient Treatment & Rehab
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24	INDICATOR		NO. OF SURRENDERERS WHO COMPLETED WELLNESS & RECOVERY INTERVENTIONS					The purpose of this form is to determine the number of surrenderers per semester (January-June, July-December), and monitor the number of who, among those surrenderers, have been referred, assessed, and who have completed any Wellness and Recovery Program interventions within the 6-month time frame. Counting shall restart at the onset of the new semester; meaning, the data on those who surrendered in the previous semester shall no longer be accounted in the next, regardless of whether they have been referred or assessed in the following semester.
25			MALE		FEMALE		TOTAL
26			BELOW 18	ABOVE 18	BELOW 18	ABOVE 18	TOTAL
27	Submission of Updated Number of Surrenderers Who Completed Wellness & Recovery Interventions
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