CHILD REGISTRATION FORM

Transcription

1 CHILD REGISTRATION FORM Health facility code

2 CHILD REGISTRATION FORM

3 CHILD VACCINATION FORM Mobile site Outreach site Indicate only if applicable Month Day Date Health facility code 9 s 14 weeks 10 weeks 6 weeks at Measles 2 Measles 1 OPV 4 IPV PCV 3 Penta 3 OPV 3 Rota 2 PCV 2 Penta 2 OPV 2 Rota 1 PCV 1 Penta 1 OPV 1 OPV 0 HepB BCG Child ID

4 CHILD VACCINATION FORM s 14 weeks 10 weeks 6 weeks at Measles 2 Measles 1 OPV 4 IPV PCV 3 Penta 3 OPV 3 Rota 2 PCV 2 Penta 2 OPV 2 Rota 1 PCV 1 Penta 1 OPV 1 OPV 0 HepB BCG Child ID Daily Vaccine Utilization Doses returned to the fridge Doses issued from the fridge Expiry date VVM Indicate if Stockout بی سی ج ی BCG ه ی پ ا ټ ی ټ س ب ی Heb B ا و پ ی و ی OPV Penta پ ی ن ت ا پی سی و ی PCV Rota ر و ت ا ا ی پ ی و ی IPV س ر خ ک ا ن/ ش ر ی Measles ټ ی ټ ی TT Use separate Child Vaccination Form for each vaccination! Signature Health worker

5 WOMEN OF CHILD-BEARING AGE REGISTRATION Health facility code / / / / / / / / /

6 WOMEN OF CHILD-BEARING AGE REGISTRATION / / / / / / / / /

7 TT VACCINATION FORM FOR WOMEN Mobile site Outreach site Indicate only if applicable Month Day Date Health facility code Not pregnant - TT Pregnant - TT ID

8 TT VACCINATION FORM FOR WOMEN Not pregnant - TT Pregnant - TT ID Use separate TT Vaccination Form for each vaccination session! Signature Health worker

9 VACCINE MANAGEMENT AND DATA FOR ACTION FORM Year Month Reporting Period Number of health workers Health facility code Vaccine Utilisation Doses received within the Doses used in the (C D) E Doses remaining at the end of the D Total doses stocked in the (A + B) C Expiry date VVM Doses B Doses in stock at the beginning of the A BCG Hep B OPV Penta PCV Rota IPV Measles TT Syringe Utilisation Quantity used in the (C D) E Quantity remaining at the end of the D Total quantity stocked in the (A + B) C Quantity received within the Expiry date Quantity B Quantity in stock at the beginning of the A 0.05 ml BCG Syringes 0.5 ml AD Syringes 2 ml Syringes 5 ml Syringes Safety box

10 VACCINE MANAGEMENT AND DATA FOR ACTION FORM Report if any actions were taken during the reporting to improve Key Performance Indicators (KPI). Cold chain inventory Installation date Specification Actions taken to improve KPI Data for action Quantity non-functioning Quantity functioning Refrigerators BCG to Measles 1 immunisation drop-out rate Cold boxes Penta 1 to Penta 3 immunisation drop-out rate Vaccine carriers TT 1 to TT 3 immunisation drop-out rate Ice packs Percentage of missed opportunities for BCG vaccination Solar panel Percentage of children that received Measles1 vaccine timely Freeze tag Pentavalent vaccine ly wastage rates Thermometer PCV vaccine ly wastage rates Fridge tag Percentage of children with incorrectly recorded vaccines Percentage of children registered with valid phone number Report all the sessions that were not held according to the schedule/plan Reason Mobile Cold chain inventory Girls Boys Outreach Fixed session Day of the Cancelled sessions Reason Fixed session Day of the vaccinator Hospitalization Date Signature Anaphylaxis HF in-charge Toxic shock Outreach 8 Death Local reaction Mobile Date Signature Indicate if you plan to have mobile session next