Region III

Province of BULACAN
Municipality of SAN RAFAEL
Barangay _______________________
(for the month of _________________ CY 2023)

Conducted Road Clearing

Operations (Check appropriate Location of Road Clearing
column) Operations (Street name/ Date of Operations
YES NO Address)

Prepared by:

Punong Barangay
ACAN
RAFAEL
___________
_______ CY 2023)

Action Taken Remarks

Attested by:

HON. MARK CHOLO I. VIOLAGO

Municipal Mayor
 FIRST TIME JOB SEEKERS MONTHLY REPORT
FOR THE MONTH OF ____ 2023

SUBMISSION OF MONTHLY NAME (FN, MI, BIRTHDA AGE* COMPLETE ADDRESS* MONTH/S OF CONTACT GENDER* CIVIL EDUCATIONAL COURSE (if
REPORT LN) TE RESIDENCIES* NUMBER (If STATUS* ATTAINMENT* applicable,
(Required)* (MM/DD/ any) put N/A if
YYYY) not
applicable)

YEAR OF MONTH OF HOUSE/UNIT BARANGAY CITY/ PROVINCE/

ENROLMENT* ENROLMENT* NUMBER, MUNICIPALIT HUC
(Required) (Required) SITIO/STREET/ Y
BLOCK
 BARANGAY MONTHLY INVENTORY OF VACCINATED POPULATION

REGION:_________________
PROVINCE: ________________
CITY/MUNICIPALITY: __________________
BARANGAY: _________________________
A. TOTAL NO. OF POPULATION (AS OF 2020)*: * Note: This shall only cover individuals 13 years old and above.
B. TOTAL NO. OF UNVACCINATED INDIVIDUALS*:
C. PERCENTAGE OF UNVACCINATED INDIVIDUALS*: Formula: B/A x 100
D. TOTAL NO. OF PARTIALLY VACCINATED INDIVIDUALS*:
E. PERCENTAGE OF PARTIALLY VACCINATED INDIVIDUALS*: Formula: D/A x 100
F. TOTAL NO. OF FULLY VACCINATED INDIVIDUALS*:
G. PERCENTAGE OF FULLY VACCINATED INDIVIDUALS*: Formula: F/A x 100
H. TOTAL NO. OF INDIVIDUALS WITH BOOSTER SHOT*:
I. PERCENTAGE OF INDIVIDUALS WITH BOOSTER SHOT*: Formula: H/F x 100
AS OF (insert date): ___________________

Prepared by Approved by

Name and Signature of Barangay Secretary/Health Worker Name and Signature of Punong Barangay

PRIMARY SERIES OF COVID-19 VACCINE

(Note: 1. If brand is "Janssen, put NA in the column for "2nd Dose"; Partially Fully BOOSTER DOSE
Unvacinnated? Shot?
PutVaccination
"None" if unvaccinated) vacinnated? (Put Vacinnated? (Put
No. Full Name Date of (Put 1 if Yes or (Put 1 if Yes or
Brand 1 if Yes or 1 if Yes or Date of Vaccination Brand
1st Dose 2nd Dose 0 if No) 0 if No)
0 if No) 0 if No)
1 EX: JUAN DELA CRUZ June 17, 2021 July 19, 2021 Sinovac 0 0 1 1 January 6, 2021 Moderna
2 EX: JANE DOE October 20, 2021 NA Janssen 0 0 1 0
3 EX: MARIA SANTOS May 27, 2021 Pfizer 0 1 0 0
4 EX. JUANA DELA CRUZ None None None 1 0 0 0
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
TOTAL 1 1 2 1
 Katarungang Pambarangay Compliance Report
as of ___ Quarter FY 2023

Actions Taken by the Lupong Tagapamayapa (2)

Nature of Disputes (2a) Settled Cases (2b) Unsettled Cases (2c) ESTIMATE
Total (2c.7) D
GOVERNM
Name of
ENT
Barangay Total (2a.4) Total (2b.4) SAVINGS
Referred to (In PhP)*
Repudiated Withdrawn Pending Dismissed Certified Concerned (3)
Criminal Others Mediation Conciliation Arbitration Cases Cases Cases Cases Cases Agencies
(2a.1) Civil (2a.2) (2a.3) (2b.1) (2b.2) (2b.3) (2c.1) (2c.2) (2c.3) (2c.4) (2c.5) (2c.6)

I HEREBY CERTIFY THAT I HAVE REVIEWED THE CONTENTS AND HE

Prepared by: the veracity or correctness of the data or information contained in this Repo

Barangay Secretary Punong Barangay

Date: _______________ Date: ______________________

Instructions:
1. Write the name of the LGU under Column 1.
2. Under column Nature of Dispute, put the total number of cases filed under sub column Criminal,Civil and Others with the corresponding
3. On the Actions Taken by LT, put the total number of Settled Cases by Mediation, Conciliation and Arbitration with the corresponding tot
4. On the Actions Taken by LT on the Unsettled Cases, put the total number of Repudiated, Withdrawn, Pending, Dismissed, Certified Cases and Cases referred to other Agencies with the correspondin
5. On the column "Estimated Government Savings " multiply the total number of settled cases by the Estimated Adjudication cost per case of Php9,5
Quarterly Reports to be submitted on the following dates:
 COMPLIANCE TO BARANGAY FULL DISCLOSURE POLICY
(Per DILG MC No. 2014-81 dated July 2014 amending DILG MC No. 2010-49)
For the Month of _______________

San Rafael,Bulacan

ANNUAL QUARTERLY MONTHLY

PLACE AND DATE OF

POSTING
Name of Summary of 20%
Barangay Annual List of Itemized Monthly Collection and Disbursement
Barangay Income and Component
of IRA
Budget Expinditures Procurement Notice of Award
Utilization
Plan
Month of Month of Month of Place Date

Prepared by Submitted by Noted by

Barangay Treasurer Barangay Secretary Punong Barangay

 ANNEX "A"
(Form 1 for Barangay)

MANILA BAY CLEAN UP, REHABILITATION AND PRESERVATION PROGRAM

Date: _____________________________

CONDUCT OF WEEKLY CLEAN UP DRIVE

BARANGAY: CITY/MUNICIPALITY:

A. Barangay Clen-up Drive

Water Body/ Length Covered Volum of Waste

Date Barangay Waterway covered (in Meters) Collected (in
(if applicable) kilograms)

Details on Disposal Other Remarks

B. Photo Documentation (attach photos of the clean-up drive here

C. List of Attendees and Total Number of Volunteers

Prepared by:

Committee Chair on Environment or Authorized Representative Date

Certified Correct:

Punong Barangay or Authorized Representative Date

MANILA BAY CLEAN UP, REHABILITATION AND PRESERVATION PROGRAM

Attendance

Date: ___________________________________________

Names Designation Signature

 VAW Form 1
BARANGAY DATA CAPTURE FORM
MONITORING OF INCIDENCE ON VIOLENCE AGAINST WOMEN (VAW) DURING THE COVID-19
PANDEMIC
For the Month of _______

Region:___________________
Province:______________________________________
City/Municipality:_______________________________
Barangay:____________________________________

TYPES OF VIOLENCE (2) ACTIONS TAKEN BY THE BARANGAY (3)

Others
Psychologi
VAW Referred for Referred for (ex:
Physical Sexual cal/ Economic Referred to Referred to Referred to Referred to
VICTIM/S Issued BPO Medical Legal Referred to
DATE Abuse Abuse Emotional Abuse LSWDO PNP NBI Court
(Total) (3a) Treatment Assistance NGOs,
(2a) (2b) Abuse (2d) (3b) (3c) (3d) (3g)
(1) (3e) (3f) FBOs)
(2c)
(3h)

✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 pls. specify

TOTAL

*If ✔, encode "1" on the applicable fields

*If "Others," please specify

Prepared by: Submitted by:

VAWC Punong Barangay
 BARANGAY
MONITORING OF INCIDENCE ON VIOLENCE AG
For the M

Region:___________________
Province:______________________________________
City/Municipality:_______________________________
Barangay:____________________________________

GENDER TYPES OF VIOLENCE

(2) (4)

Psychologi
VAC Physical Sexual cal/
Male Female AGE Neglect
Abuse Abuse Emotional
DATE VICTIM/S (2a) (2b) (3) (4a) (4b) Abuse
(4d)
(1)
(4c)

✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1

TOTAL
*If ✔, encode "1" on the applicable fields *Immediate Family Member/s
*If "Others," please specify *Other Close Relative/s – unc

Prepared by:
VAWC DESK OFFICER
 BARANGAY DATA CAPTURE FORM
E ON VIOLENCE AGAINST CHILDREN (VAC) DURING THE COVID-19 PANDEMIC
For the Month of : _____________

PERPETRATORS ACTIONS TAKEN BY THE BARANGAY/BCPC

(5) (6)

Immediate Others
Other Close Acquaintan Local Law Referred to Referred to Referred to
Family Stranger (ex:
Relative ce Official Enforcer LSWDO PNP NBI
Member (5d) Guardian)
(5b) (5c) (5e) (5f) (6a) (6b) (6c)
(5a) (5g)

✔=1 ✔=1 ✔=1 ✔=1 ✔=1 ✔=1 pls. specify ✔=1 ✔=1 ✔=1

*Immediate Family Member/s – parents and siblings

*Other Close Relative/s – uncles, aunts, grandparents, cousins, etc.

Submitted by:
Punong Barangay
NDEMIC

S TAKEN BY THE BARANGAY/BCPC

(6)
Others
Referred for Referred for (ex:
Medical Legal Referred to
Treatment Assistance NGOs,
(6d) (6e) FBOs)
(6f)

✔=1 ✔=1 pls. specify

angay