gistfile1.htm

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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_0">Prepared By
</label>
<label class="ss-q-help" for="entry_0"></label>
<input type="text" name="entry.0.single" value="" class="ss-q-short" id="entry_0"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_1">BHS/RHU Name
</label>
<label class="ss-q-help" for="entry_1"></label>
<input type="text" name="entry.1.single" value="" class="ss-q-short" id="entry_1"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_2">Quarter
</label>
<label class="ss-q-help" for="entry_2"></label>
<input type="text" name="entry.2.single" value="" class="ss-q-short" id="entry_2"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_3">Year
</label>
<label class="ss-q-help" for="entry_3"></label>
<input type="text" name="entry.3.single" value="" class="ss-q-short" id="entry_3"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_4">Municipality/City
</label>
<label class="ss-q-help" for="entry_4"></label>
<input type="text" name="entry.4.single" value="" class="ss-q-short" id="entry_4"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_5">Region
</label>
<label class="ss-q-help" for="entry_5"></label>
<input type="text" name="entry.5.single" value="" class="ss-q-short" id="entry_5"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_6">Province
</label>
<label class="ss-q-help" for="entry_6"></label>
<input type="text" name="entry.6.single" value="" class="ss-q-short" id="entry_6"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_7">Pregnant w/4 or more Prenatal visits
</label>
<label class="ss-q-help" for="entry_7"></label>
<input type="text" name="entry.7.single" value="" class="ss-q-short" id="entry_7"></div></div></div>
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<div class="ss-item  ss-text"><div class="ss-form-entry"><label class="ss-q-title" for="entry_8">Pregnant given TT2 plus
</label>
<label class="ss-q-help" for="entry_8"></label>
<input type="text" name="entry.8.single" value="" class="ss-q-short" id="entry_8"></div></div></div>