TIRUPPUR HEALTH UNIT DISTRICT

MALARIA - NAMMIS BASE INPUT FORM

Name of the PHC : urban phc - palladam

Month & Year : OCT-14

FI
S.no

Name of the HSC

Population

( 1 to 15 th )

F 2 ( 16 to 31 st )
Positve
Case

BS Collected

Positve
Case

BS Collected

HI

VHN

Total

HI

VHN

Total

HOW

palladam west

26

32

58

26

22

48

Total

naranapuram

21

30

51

27

20

47

ACTIVE- 387

vadugapalayam
pudur

23

29

52

20

24

44

Pasive - 112

rangasamudram

18

30

48

20

19

39

Active
f1-- 209

5
6

f2---178
mobile team

24

Passive-112

mmu-24

Total-523

10
11

mmu-f1-

12

f2

13

total-

Total

PHC PASSIVE

88

F1

121

:214

209

93

85

F 2 : 158

178

12
12
24

TIRUPPUR HEALTH UNIT DISTRICT

NATIONAL MALARIA ERADICATION PROGRAMME

ACTIVE SURVEILLANCE REPORT

District code :
Block Code :
Month & Year :
Name of the HSC :
S.n
o

Village
Code

Name of the PHC :

PHC Code :
HSC Code :
BS Collection

Total BS

Positive

Name of the Village

HI

VHN

Collected Examined

Pv

Pf / mixed

Total

ACTIVE SURVEILLANCE REPORT

District code :
Block Code :
Month & Year :
Name of the HSC :
S.n
o

Village
Code

Name of the PHC :

PHC Code :
HSC Code :
BS Collection

Total BS

Positive

Name of the Village

HI

VHN

Collected Examined

Pv

Pf / mixed

Total

ACTIVE SURVEILLANCE REPORT

District code :
Block Code :
Month & Year :
Name of the HSC :
S.n
o

Village
Code

Name of the PHC :

PHC Code :
HSC Code :
BS Collection

Total BS

Positive

Name of the Village

HI

VHN

Collected Examined

Pv

Pf / mixed

Total

ACTIVE SURVEILLANCE REPORT

District code :
Block Code :
Month & Year :
Name of the HSC :
S.n
o

Village
Code

Name of the PHC :

PHC Code :
HSC Code :
BS Collection

Total BS

Positive

Name of the Village

HI

VHN

Collected Examined

Pv

Pf / mixed

Total

TIRUPPUR HEALTH UNIT DISTRICT

NTIONAL ANTI MALARIA PROGRAMME
PASSIVE SURVEILLANCE REPORT
Name of the PHC :

URBAN PHC- PALLADAM

District Code :

S.no

PHC Code

Code No:

Block Code :
Passive Agency
Code

Month & Year : OCT-14

PHC Code :
Fever
Treated

New OP Cases

BS
Collected

Positive

BS
Examined
Pv

urban phc
1 palladam

uphc-p

921

112

112

112 -

Pf / mixed

No of
Clinical
Malaria

Total

Remarks

Stock Report
Tab Chloroquine

Tab Primaquine 2.5 mg

Tab Primaquine 7.5 mg

Micro Slides

NIL

Medical Officer ,
Govt Primary Health Centre ,

TIRUPPUR HEALTH UNIT DISTRICT

Monthly Larvicide & Adulticide Stock Report :
Name of the PHC :

S.no

Drugs/insecticides/larvic
ides

Abate

Pyrethrum

Malathion

Tab Chloroquine

Tab Primaquine 2.5 mg

Tab Primaquine 7.5 mg

Micro Slide

Month :

Opening Balance
First day of the
Month

Qty received
from DDHS
Office

Total

Consumption During the Month

Utilized

Balance

Medical Officer ,

Expiri

TIRUPPUR HEALTH UNIT DISTRICT

Monthly Fogging report
Month:
Date

Name of the PHC :

Name of the
HSC

Total

Name of the Village

Houses
Covered

Quantity of
Population Pyrethrum/Tec
Covered .Malathiyan
spent ml

Diseal

Petrol

LPG Cylinder

TIRUPPUR HEALTH UNIT DISTRICT

STOCK POSITION OF DISINFECTANTS / MEDICINES (EPIDEMIC SCHEME)

Name of PHC :

Sl.No.

Bleaching
Powder

Month & Year :

Phenyle
(Ltr.)

Chlorine
Tablet

Lime
Powder in
Kgs.

Buffer Salt

Culture
Tube

Cotrimaxazole
Cap. Doxy

Tab. Metro
Tab.

Syp.

ORS
Packets

Medical Officer ,

IVF Ringer
lactate

MONTHLY REPORT OF NOTIFIABLE INFECTIOUS DISEASES

Name of the HUD : Tiruppur.
RURAL

Sl.
No
.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Name of the PHC :

Month :
(Area

covered by PHCs)

Notifiable Disesses

CASES

URBAN
Area not covered by PHCs)

DEATHS

CASES

TOTAL

DEATHS

CASES

DEATHS

D/M

U/M

D/M

U/M

D/M

U/M

D/M

U/M

D/M

U/M

D/M

U/M

Cerebrospinal Fever / Meningitis

Chickenpox
Diphtheria
Leprosy
Cholera
Measles
Plague
Rabies
Scarlet Fever
Smallpox
Typhoid / Enteric Fever
Tuberculosis
Hepatitis - A
Hepatitis - B
Epidemic Influenza
Whooping Cough
Viral Encephalitis / AES
Haemorrhagic Fever / Dengue / DSS
Malaria
Tetanus
Poliomyelitis
HIV / AIDS
Chikungunya
AH1N1 (Swineflu)
Avian influenza
Total

E-mail id: dphnidmr@gmail.com

Medical Officer ,

U
23

30

WEEKLY REPORT OF ADD / CHOLERA

Tiruppur.

Month :

Name of the PHC :

D/W U/W
10

11

Prog.Tot

U/W

D/W

D/W

PRG. TOT

Deaths

Cholera
+ve

D/W

Cases Deaths Cases

Collection

OTHERS

Prog.Total

No of ORS
Packets Issued

Bore Well

On date

No.of Houses
Disinfected

CholorinationParticulars
Open Well

No. of stool sample coll &

sent to mic.lab

No of ADD Cases

OHT

No. of
Villages
where
cases
ocurred

Period :

GLR

S.No.

Name of the Village

Week no :

Infiltration
Gallery

Name of the HUD:

12

13

14

15

16

17

18

19

20

21

MONTHLY REPORT OF ADD / CHOLERA

Name of the HUD:

Tiruppur.

Month :

Name of the PHC :

10

11

D/W

U/W

PRG. TOT

D/W

D/W

U/W

OTHERS

D/W

Bore Well

Deaths

Cholera +ve cases

Open Well

Cases

Collection

OHT

Deaths

Prog.Total

No of ORS
Packets Issued

GLR

Cases

On date

No.of Houses
Disinfected

CholorinationParticulars
Infiltration
Gallery

S.No.

Name of the Village

No. of stool sample coll & sent to

mic.lab

No of ADD Cases

No. of
Villages
where
cases
ocurred

12

13

14

15

16

17

18

19

20

Deputy Director of Health Services,

Tiruppur.

Prog.Tot

No of ORS
Packets Issued

21

ervices,

NATIONAL IODINE DEFICIENCY DISORDER CONTROL PROGRAMME

Name of the PHC :

Month:
Salt Content

Salt Samples collected from

No. of
Shops/ No. of Salt
CNCs.HHs Samples
/Schools
tested
Visited

Nil

A.
Shops
CNCs
House Holds visits
Schools

B. TESTING OF STATUTORY AND NON STATUTORY SALT SAMPLES

No.of statutory salt samples lifted & sent to

1 Food Lab

No.of non-statutory salt samples lifted & sent

2 to Food Lab
C

IODINE DEFICIENCY DISORDERS DETECTED DURING THE MONTH

( New cases only)

1 Goitre
2 Squint Eyes
3 Deafness
4 Stunted Growth
a) Cretinism
b) Dworfism

5 Mentally Retarded
D IEC Activities
Health Education sessions in schools by PH

1 staff

2 Health Education to AN mothers in AN clinics

Medical Officer ,

<15
ppm

>15
ppm

TIRUPPUR HEALTH UNIT DISTRICT

Form II Monthly report of Animal bite Victims Receiving Treatment AT ARC's
Name of the HUD : Tiruppur
S.no

Month :
Details

Total No of Patients attending the ARC

District Head Quarters

Hospital , Taluk & Non
Taluk Hospitals
New Cases
Old Cases
Total

Biting Animal for (New Cases Only)

a)Dog
b)Cat
C)Monkey
d)Mangoose
e)Any Others (Specfy)

Category of bite ( New Cases only )

a)Licks on insect Skin
b)Minor Scratches or abrasions Without bleeding
C)Single or Multible bite with bleeding contamination of
Mucous membrane

Wound Washing Facility At ARC Yes / No

Vaccine Used at ARC

a)Quantity Procured
b)Quantity Utilized
C)Mention Shortage if any

ARS Used at ARC

a)Quantity Procured
b)Quantity Utilized
C)Mention Shortage if any

Vaccination given by (Old & New Cases)

a)IM Route Essen Schedule on day 0 ,3,7,14,28
b) ID Route (Update Thai red cross Regimen 2 - 2 - 2 -0 2)
C)any Other remarks

Medical
College
Hospitals

PHC

Total