INSTRUCTIONS FOR LONG ACTING FAMILY PLANNING REMOVAL
REGISTRATION AT Federal Democratic Republic of Ethiopia
HEALTH CENTER / CLINIC / HOSPITALMinistry of Health
INSTRUCTIONS FOR LONG ACTING FAMILY PLANNING REMOVAL
The register is kept in FP room (HC/Clinic/Hospital), Completed by Family Planning Service
Provider REGISTRATION AT HEALTH CENTER / CLINIC / HOSPITAL
The register is kept in FP room (HC/Clinic/Hospital), Completed by Family Planning Service Provider
Location information to be completed at front of register:
Location information to be completed at front of register:
Region Write region name where the facility is located
Zone/Sub-City /Woreda Write Zone/Sub-City /Woreda name where the facility is located.
Name of Health Write the name of the health facility where the service was provided.
Facility
Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year
(DD/MM/YY)
Register end date Write the date of the last entry in the register, written as (EC) Day / Month /
Year(DD/MM/YY)
SN Datum Comments
Identification: Personal information
1 S.N Write the sequential serial number in registration book; to be
entered on client’s registration card for later identification in
register
2 MRN Medical Record Number Unique individual identifier used on
medical information folder, for HC and hospital.
3 Name of client Write the name of the client
4 Age Write age in years
Family Planning Long acting Removal services:
Registration
5 Reg. date Write Date client registered in this registration book, written as
(DD/MM/YY) (EC) Day / Month / Year (DD/MM/YY)
6 Date of insertion Write Date of insertion Day / Month / Year (DD/MM/YY)
7 Type of LAFP used Write type of LAFP method provided as follows:
Implanon - Implanon Implant
Sino-Implant- Sino Implant
Jadell -Jadelle Implant
IUD- Intrauterine Contraceptive Device
Federal Democratic Republic of Ethiopia
Ministry of Health
8 Place of LAFP received (write Write code for type of facility LAFP provided abbreviate as
code) follows:
Within facility WI
Out of Facility
Hospital 1
Health center 2
Health Post 3
Private clinic 4
9 Date of Removal service
provided Write Date of Removal service provided as (EC)
Day/Month/Year(DD/MM/YY
10 LAFP method duration used Write duration of method used in month (if the client used only
in month one month we can put =1, if it is two month =2 and so on )
11 Reasons of removal Write code for reasons of LAFP removal
a) On recommended time
b) Side effect
c) Want to get pregnant
d)Misconception
e) Others
Counseling and testing
12 HIV test offered (√) Tick (√) if HIV test offered under provider initiated HIV
counseling and testing guidelines
13 HIV test performed (√) Tick (√) if client tested for HIV/AIDS and received test result
14 HIV Test results (P/N) Write P in red pen if test result is Positive; N in normal color
of pen if test result is negative
15 HIV specific contraceptive Tick (√) if HIV specific contraceptive counseling offered.
counseling offered (√)
16 HIV Positive and linked to Tick (√) if the client is HIV positive and linked to ART
ART (√)
17 Targeted population category Write the code target population category listed below the
write code register. an individual needs to be assigned only in one category
that best describe him/her.
A. Female Commercial Sex workers, B. Long distance
drivers, C. Mobile/Daily Laborers, D. Prisoners, E. OVC
F. Children of PLHIV, G. Partners of PLHIV, H. Other
MARPS, I. General population
18 Post Removal Contraceptive Write the abbreviate of Contraceptive method provided (record
provided modern methods only) as follows:
MaC -Male Condom
FeC -Female Condom
OC -Oral Contraceptive
Inj -Injectable
EC -Emergency Contraception
Diaph -Diaphragm
IUCD- Intrauterine Contraceptive Device
Imp -Implant
19 Remarks Any additional suggestions, comments…
Federal Democratic Republic of Ethiopia
Long Acting Long
Family
ActingPlanning Removal
Family Planning removal Registrer
registrer Ministry of Health
Identification
Identification Long
LongActing FamilyPlanning
Acting Family Planning Removal
Removal services
services
Personal information
Personal information Registration
Registration Counselling andtesting
Counselling and testing
service
(DD/MM/YY)
Removal Contra-
Reason for Removal
dura-
service
provided
duration
in month
performed
provided (DD/MM/YY)
offered(√)(√)
code
code)
Result(P/N)
and to
offered (√)/ methods
used
specific coun-
Reason for Removal
writecode
(√)
Testperformed
population
(write code)
LAFPused
Removal
of LAFP
and linked
code
provided
seling / methods
Target population
method
Date of insretion
Testoffered
ART
(write
TestResult
Date ofofRemovl
Categorywrite
HIV Positive
of LAFP
month
Post Removal
Contraceptive
LAFPmethod
TypeofofLAFP
(DD/MM/YY)
(√)
received use
HIVspecific
used
counseling
provided
to
Date of
received
Category
Place
HIV Test
HIVTest
HIVTest
ART (√)
Reg. date
Positive
ceptive
date
tion in
linked
(P/N)
Target
Insertion
LAFP
Place
Date
used
Type
S.N
S.N MRN Name
Name of Client
HIV
MRN of Client Age (DD/MM/YY)
Age (DD/MM/YY) (DD/MM/YY) Remark
HIV
HIV
HIV
Remark
(√)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Reason Place of LAFP received: Col. 8 Targeted population category
ReasonforforRemoval:
Removal Col. 11 0-6month >6month
A. Female Commercial Sex workers
a) On recommeded time Within facility WI Implanon B. Long distance drivers
b) Side effect Out of Facility Sino-Implant C. Mobile workers/daily laborers
c) Want to get pregnant Hospital 1 Jadell D. Prisoners
d)Misconception Health center 2 IUD E. OVC/
e) Others [Link] of PLHIV
Health Post 3 Others
[Link] of PLHIV
Private clinic 4 Total Removal H. Other MARPS
[Link] Population
FMOH V1 2009
