Kara Diva Vi

Total
Mobile teams
No. of Supervisors required
No. of Mobile team members

required
Transit points
No. of sites to be covered
No. of team members

required
House-to-House activity
No. of transit points
No. of Team members

required
No. of Teams required
Booth activity
Estimated houses in the area

( from the last IPPI round )
No. of Team Members

required
No. of Vaccination Booths

required
Estimated number of children

below 5 years
Urban / Rural
Name of PHC / UHP / Mpty
IPPI 2014
Form 1
Manpower Planning Form
Name of HUD / Corporation : ________________________________________

Round: Jan 2014 / Feb 2014
Form 2
IPPI 2013
Vaccine and Cold Chain Planning Form
puliampatti
rural
veppankottai palayam
kamanaikanpalayam
krishnapuram
Total
Available for vaccine carriers

and cold boxes
Ice packs
Required for vaccine carriers
and cold boxes
Deep freezer
Yes / No
Functioning
ILR
Yes / No
Available
Cold boxes
Required
Available
Vaccine carriers
Required
Total OPV vials required for each

round
Total OPV doses required for each

round
Estimated number of children below

5 years
Estimated population
Urban / Rural

TIRUPPUR
HSC.PULIAMPATTI
Comments (availability
of power supply,
stabilizers,
thermometers, etc.)
Total
Specify type
Additional Vehicles required

for supervisors
No. of supervisors using own

transport
Transport for mobile teams
No. of Supervisors
Specify type
Additional Vehicles needed
Vehicles available
Transport for supply of vaccine

and logistics
Vehicles required
Specify type
Additional Vehicles needed
Vehicles available
Other logistics
Vehicles required
Indelible Marker Pen
Logistics for
Supervisors
Chalk
Vaccinator tally sheets
Reporting formats
P sweep tally sheet
Check lists
IPPI 2013
Form 3
Logistics and Transport Planning Form

Transport for supervision
IPPI 2013
Form 4
Booth Planning
Round: Jan
Name of HUD / Corporation : ___________________
Booth Number
678
679
680
681
Name of PHC / UHP / Mpty:________________________________________

PULIAMPATTI
Booth Location
KARADIVAVI
KARADIVAVI PUDUR
MALLAGOUN DEN PALAYAM
M.UTHUKULI
Name of Team Members
Designation
DHANAPACKIAM
VHN
LAKSHMI
AYAH
NIRMALA
VOLN
SENTHIL
VOLN
SRIDHAR
TEACHER
ARTHI
VOLN
ANNAMMAL
SO
SIVAGAMI
AYAH
MARAGADHAM
AWW
RAJATHI
AYAH
GOKILAMANI
AYAH
KAVITHAMANI
VOLN
SIVAGAMI
SO
SARASWATHI
AYAH
SHANTHAMANI
VOLN
KARTHIK
VOLN
682
ARAKULAM
ANGATHAL
AWW
NEELA
AYAH
BALAJI
VOLN
BHANUMATHI
VOLN
IPPI 2013
Form 4A
House to House (H-to-H) Planning

Name of HUD / Corporation : Tirupur
Name of PHC / UHP / Mpty: Puliyampatti
Name of Supervisor : Dr.Sampoornam
Team
Number
st
H-to-H 1 day
(Monday)
Name of team members
north st
678
dhanapackiam,,nirmala
Name & Address of first house

owner with landmark
Name & Address of last house
owner with landmark
north st
ganthi nagar
dhnanapackiam
rajendiran
rangasami
nataraj
No. of houses in the area
laksmi,,senthil
Description of area to be
covered
owner with landmark
owner with landmark
200
679
sridhar,,arthi
covered
owner with landmark
owner with landmark
field huts
shanmugam
karuppusami
mohan
senthil kumar
150
annammal,,sivagami
field huts
shaktivel
palanal
srithar
krishnamoorthi
65
680
maragatham,,rajathi
60
gounder palayam edayar palayam

muthu sami
nachi muthu
nagarhithinam
muthukrisnan

covered
181
adst karadivavi
pudur

covered
owner with landmark
owner with landmark
200
adst
Addl. Days if required
nd
H-to-H 2 day
(Tuesday)
60
school st
52
mariyamman koil
st
Is it HRA*?
Write Y/N
680
maragatham,,rajathi

owner with landmark
owner with landmark
muthaiyan
thamburaj
murugan
kanna\n
gokilamani,,,kavithamani
covered
owner with landmark
owner with landmark
90
west st
gounder st
babu
muthu krisnan
krishnamoorthi
manokaran
681
sivagami,,saraswatyi
covered
owner with landmark
owner with landmark
90
sahnthamani,,karthik
682
angathal,,neela
balaji,,bhanu priya
64
m.uthukuliadst
gounder st
murugesan
nathimuthu
vadivel
kathirvel

covered
owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
90
20
20
field huts
field huts
duraisami
murugasami
velingiri
dhavasi
50
60
east gounder st
west gounder st
pugalenthi
balaji
duraisami
ranganadhan
50
50
chatti kutti
pudu kadu
narayanan
kuppusami
parthasarathi
velesami
50
51
NID/ SNID
Template for House to House Planning

District: ___________________
Block/Urban Area: _____________________
Name & Mobile no of Supervisor: ____________________________________
Planning Unit: ________________
Designation: _____________________ Name and Mobile no of M
Name of Vaccinator
Name & description of area to be

covered
Designation
Mobile No
Is this an identified HRA?
If yes, type of area

Name & address of 1st house owner
with land mark
Day 1
Yes / No
Urban slum/ Nomads/
Brick kiln/ Construction site
Others/ Settled HRA
Via
Name of Vaccinator
Designation
Via
Name and address of last house
owner with land mark
Meeting point before afternoon activity
No of houses in the area
Mobile No
Name and mobile no of Influencer/s

Area specific routine immunization information
Name of Sub centre

Name of ANM
Location of site where RI session is held
Day of RI
Name of ASHA/ local mobiliser/ link worker supporting RI

session
Name of AWW supporting RI session
Signature of Supervisor
Form: 4B
Template for House to House Planning
____________
___
Planning Unit: ________________
Round: _____________________
Designation: _____________________ Name and Mobile no of MO I/C______________________________

Day 5
Day 2
Day 3
Day 4
Yes / No
Yes / No
Yes / No
Yes / No
Urban slum/ Nomads/

Urban slum/ Nomads/
Urban slum/ Nomads/
Urban slum/ Nomads/
Brick kiln/ Construction site Others/ Brick kiln/ Construction site Others/ Brick kiln/ Construction Brick kiln/ Construction
Settled HRA
Settled HRA
site Others/ Settled HRA site Others/ Settled HRA
Area specific routine immunization information
Signature of Medical Officer
NID/SN NID/SNID
area planning Brick kilns, construction sites, nomadic population groups etc
District:
Block/ Urban Area:
Medical Officer I/C (Name & Tel No): ____________________
Timing of visit
Address of area
Is this HRG site
Type of site
Is this site linked to RI
session site
Day 1
Planning Unit:
Supervisor (Name & Tel No): ______________________
Site 1
Site 2
Yes / No
Yes / No
Nomad / Brick Kiln /
Construct Site
/Other

Construct Site /Other
Yes / No
Yes / No
Site specific Routine Immunization Information
Name of Sub Center

Name of ANM
RI session site
Day of RI session
Supporting ASHA/ Link worker/ mobilizer
AWW supporting session
Timing of visit
Address of area
Is this a HRG site
If yes, type of site

session site
Day 2
Yes / No
Yes / No
Construct Site
/Other
Yes / No
Yes / No
Name of Sub Center

Name of ANM
RI session site
Day of RI session
Timing of visit
Address of area
Is this a HRG site
If yes, type of site

session site
Day 3
Name of Sub Center
Name of ANM
RI session site
Day of RI session
Yes / No
Yes / No
Construct Site
/Other
Yes / No
Yes / No
Ro

Note: Each site should be visited at least twice during the SIA. Starting time and ending time should be indicated in the row of Timing of visit.
Form 4 D
Unit:
Round:
): ______________________
Site 3
Site 4
Yes / No
Yes / No

Nomad/ Brick Kiln/

Yes / No
munization Information
Yes / No
Yes / No
Yes / No

Nomad/ Brick Kiln/

Yes / No
Yes / No
Yes / No
Yes / No


Yes / No
Yes / No
ow of Timing of visit.
IPPI 2013
Form 4C
Transit Point Planning


Name and Address of
Transit Point
Shift 1
Shift 2
Timing of the shift
Name of Supervisor
Timing of the shift
Name of Supervisor
Timing of the shift
Name of Supervisor
Timing of the shift
Name of Supervisor
Note : Teams should preferably work in shifts. Starting time and ending time should be indicated in the row of Timing of the shift
Addl. Shift if required
an 2014 / Feb 2014
IPPI 2013
Form 5
Daily Miking Form


S. No.

Description of the area to be covered
Time
Name of person monitoring miking
Time
Time

Kara Diva Vi

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Total

No. of Mobile team members

No. of team members

No. of transit points

No. of Team members

No. of Teams required

Estimated houses in the area

No. of Team Members

No. of Vaccination Booths

Estimated number of children

Name of PHC / UHP / Mpty

Manpower Planning Form

Name of HUD / Corporation : ________________________________________

Vaccine and Cold Chain Planning Form

Round: Jan 2014 / Feb 2014

Available for vaccine carriers

Total OPV vials required for each

Total OPV doses required for each

Estimated number of children below

Name of PHC / UHP / Mpty

Name of HUD / Corporation : ________________________________________

Additional Vehicles required

No. of supervisors using own

Transport for mobile teams

Name of HUD / Corporation : ________________________________________

Additional Vehicles needed

Transport for supply of vaccine

Additional Vehicles needed

Indelible Marker Pen

Vaccinator tally sheets

P sweep tally sheet

Name of PHC / UHP / Mpty

Logistics and Transport Planning Form

Transport for supervision

Name of HUD / Corporation : ___________________

Name of PHC / UHP / Mpty:________________________________________

MALLAGOUN DEN PALAYAM

Name of Team Members

Round: Jan 2014 / Feb 2014

House to House (H-to-H) Planning

Name of HUD / Corporation : Tirupur

Name of PHC / UHP / Mpty: Puliyampatti

Name of Supervisor : Dr.Sampoornam

Name of team members

Name & Address of first house

No. of houses in the area

gounder palayam edayar palayam

No. of houses in the area

No. of houses in the area

No. of houses in the area

Addl. Days if required

Name & Address of first house

No. of houses in the area

No. of houses in the area

No. of houses in the area

Template for House to House Planning

Block/Urban Area: _____________________

Name & Mobile no of Supervisor: ____________________________________

Planning Unit: ________________

Designation: _____________________ Name and Mobile no of M

Name & description of area to be

Is this an identified HRA?

If yes, type of area

Designation: _ Name and Mobile no of MO I/C__________