IPPI Forms - 2013

IPPI 2013
Form 1
Manpower Planning Form
Name of HUD / Corporation : ___Tirupur HUD Palladam Block Phc: Puliampatti____________________________________
Rangasamuthiram R
2063
10
20
20
Puliampatty
1581
16
16
K.Ayyampalayam
1859
10
20
20
Karadivavi
1586
10
20
20
Vadugapalayampudur
R
2459
12
24
24
Chittambalam
1802
10
20
20
11350
60
120
30
120
Total
No. of Mobile team members

required
Mobile teams
No. of sites to be covered
No. of team members

required
Transit points
No. of transit points
No. of Team members

required
No. of Teams required
Estimated houses in the area

( from the last IPPI round )
House-to-House activity
No. of Team Members

required
No. of Vaccination Booths

required
Estimated number of children

below 5 years
Urban / Rural
Name of PHC / UHP / Mpty
Booth activity
No. of Supervisors required
Round: Jan 2013 / Feb 2013
Form 2
IPPI 2013
Vaccine and Cold Chain Planning Form
Deep freezer
Yes / No
ILR
Yes / No
Rangasamuthiram
7516
790
1060
53
10
40
Puliampatty
6352
557
740
37
32
K.Ayyampalayam
7134
595
800
40
10
40
Karadivavi
6094
466
640
32
10
40
VadugapalayampudurR
11567
1121
1700
85
12
48
6765
679
900
45
10
40
45428
4208
5840
292
60
Chittambalam
Total
40
240
Available for vaccine carriers

and cold boxes
Ice packs
Required for vaccine carriers
and cold boxes
Functioning
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
Name of HUD / Corporation : _Tirupur HUD Palladam Block Phc: Puliampatti__________________________________

Comments (availability
of power supply,
stabilizers,
thermometers, etc.)
4 Hourse Stabilizer
Avaibale
250
IPPI 2013
Form 3
Logistics and Transport Planning Form
Rangasamuthiram 5
45
25
5 10 Box
10
21
Puliampatty
38
20
4 8 Box
17
K.Ayyampalayam 5
44
25
5 10 Box
10
21
Karadivavi
40
25
5 10 Box
10
21
Vadugapalayampudur
6
72
30
10
6 12 Box
12
25
Chittambalam
Total
5
5
40
25
5 10 Box
10
21
30
279
150
44
30 60 Box
60
126
2 4 Wheelar4
Specify type
No. of supervisors
using own transport
Additional Vehicles
required for
supervisors
Transport for
supervision
No. of Supervisors
Specify type
Additional Vehicles
needed
Vehicles available
Transport for mobile

teams
Vehicles required
Specify type
Additional Vehicles
needed
Vehicles available
Transport for supply of

vaccine and logistics
Vehicles required
Indelible Marker Pen
Chalk
Other logistics
Vaccinator tally
sheets
Reporting formats
P sweep tally sheet
Logistics for
Supervisors
Check lists
Name of HUD / Corporation : Tirupur HUD Palladam Block Phc: Puliampatti___________________________________________

2W
IPPI 2013
Form 4
Booth Planning
Name of HUD / Corporation : ___________________
Booth Number
Booth Location
Name of Team Members
664
RANGASAMUDTHIRAM-HSC
665
KOSAVAMPALAYAM-P.U.SCHOOL
666
P.VADUGAPALAYAM
N.M.CENTER
667
VENKITTAPURAMN.M.CENTER
668
NID/SNID
Name
Name
of PHC
of PHC
/ UHP
/ UHP
/ Mpty:_________________________________
/ Mpty:________________________________________
PANNIKAMPATTI
SANTHAMANI
SHANTHI
VASANTHI
AYYADURAI
MARY
SHANTHI
PALANAL
JOTHI
jOTHI
THAVATTAL
MARIYYAMMAL
DEVI
CHINNATHANGAM
PALANAL
INDIRA
DEVI
A.PALANIYAMMAL
SIVASHANKAR
PALANIYAMMAL
RAVI
Name of local influencer/s
S.OR
AYYA
VOL
VOL
S.OR
AYYA
AYYA
VOL
CNW
AYAH
CNW
AYAH
CNW
S.AYAH
AYYA
VOL
CNW
VOL
AYAH
VOL
Form 4 A
Booth planning template

Name of HUD / PHC / Urban Area:Tirupur / Puliyampatti
Name of Supervisor: Boopathy, B/S
Booth Number
Booth Location
Round: January 2013
669
670
671
672
S.SUGUNADEVI
LAKSHMI
M.PARVATHI
MOHANA
PULIAMPATTI-HSE
KATHIRAVAN
SUBRAMANI
RANGATHAL
VEPPANKOTTAIPALAYAM-P.U SCHOOL DHANALAKSHMI
SAROJA
SUDHA
DHANDAPANI
KAMANAYAKANPALAYAMM.MCENTRE ESWARI
RADHA MANI
AMIRTHAM
RAJA
MANIMAGALAI
K.KRISHNAPURAM
VHN (VILLAGE HEALTH

NURSE)
VOL
CNW - AYAH
VOL
TEACHER
TEACHER
S.AYAH
S.AYAH
CNW
VOL
S.OR
S.AYAH
CNW
VOL
VOL
CNC AYAH
NID/SNID
Form 4 A

Name of Supervisor: Boopathy, B/S
Booth Number
Booth Location
673
K.AYYAMPALAYAM-NMC
674
CHINNIAGOUNDAMPALAYAM
675
VELAPPAGOUNDAPALAYAM
P.U.SCHOOL
676
ANNUPATTI N.M.CENTRE
Round: January 2013
V.SELVAKUMARI
SHANTHAMANI
PIRIYA
SUDHAKAR
SHANTHI
GOMATHI
NEELAVATHY
RAMATHAL
JOTHIMUTHU
KALIAMMAL
VASANTHAMANI
RAMASAMY
AMARAVATHY
VHN
N.M.AYYAH
VOL
VOL
C,N.W
N.M.AYYAH
S.AYYA
S.AYYA
VOL
S.AYYAH
S.AYYAH
VOL
CNW
676
677
JEYALAKSHMI
RAJESHWARI
RATHINAL
ANNUPATTI N.M.CENTRE
SELVI
KANNAMMAL
MUTHULAKSHMI
MUTHANDIPALAYAM P.U. ELE.SCHOOL ANITHA
N.M..AYYAH
VOL
S.AYYAH
CNW
S.AYYAH
S.AYYAH
VOL
NID/SNID
Form 4 A

Name of Supervisor: S.Vijayaraja, Food Inspector
Booth Number
678
679
680
681
682
Booth Location
Round: January 2013
K.DHANAYAPACKIAM
MANIKAM
LAKSHMI
PARVATHY
KARADIVAVI HSC
RANJIM
LAKSHMI
JANAKI
MAIAMMAL
KARADIVAVI PUDUR-SCHOOL
MARAGATHAL
SIVAKAMI
RAJATHI
MALLAIGOUNDAMPALAYAM-SCHOOL RAGAMMAL
SARSWATHI
MALARKODI
SELVI
CHITRA
M.UTHUKULI-SCHOOL
ANGATHAL
AMARAWATHY
NEELA
PAPALLVHN
ARAKKULAM SCHOOL
NID/SNID
VHN
CNW
AYYA
VOL
CNW
S.O
AYAH
AYAH
CNW
S.O
S.AYAH
S.AYAH
S.O
VOL
S.AYAH
AYAH
CNW
S.O
AYAH
AYAH
Form 4 A

Name of Supervisor: Kalaiammal CHN
Booth Number
693
694
695
696
697
698
Booth Location
Round: January 2013
LAKSHMI
NIRMALA DEVI
SELVI
VADUGAPALAYAM PUDUR PU
SASI PRIYA
BUILDING
JAMES
ESWARI
SASI PRIYA
TELC MIDDLE SCHOOL AGRAKARA ST PUSHPA
INDUMATHI
SELVI
PUNITHA
PATCHAPALAYAM VINAYAKAR KOIL TAMILSELVI
KATHAR BABE
ARUN
SARASWATHI
RAJA
BLUE BIRD SCHOOL KAMARAJAR
P.VASANTHI
MANI
ROTARY SCHOOL MANGALAM ROAD [ ESTHER
SASIPRIYA
MANGALAM ROAD)
YUVARANI
RAJAKUMAR
LAKSHMI
PUSHPA
JKJ COPLONY MILK SOCIETY
B.W.ORGANISER
B.W HELPER
N.M.HELPER
VOL
N.M.ORGANISOR
B.W. ORGANISOR
VOL
N.M.HELPER
B.W.ORGANISER
B.W.HELPER
B.W.HELPER
VOL
B.W.ORGANISER
VOL
B.W.HELPER
VOL
VHN
VOL
N.M.ORGANISOR
VOL
N.M.ORGANISOR
VOL
N.M.ORGANISOR
N.M.HELPER
NID/SNID
Form 4 A

Name of Supervisor: Kalaiammal CHN
Booth Number
Booth Location
Round: January 2013
C.NIRMALADEVI
722
CHITTAMBALAM-HSE
V.H.N
722
CHITTAMBALAM-HSE
723
CHINNAVADUGAPALAYAM-SCHOOL
724
ALUTHUPALAYAM-SCHOOL
725
PILLIAPPAMPALAYAM-SCHOOL
726
PANAPALAYAM-CMNMC
N.SELVARAJ
S.ESWARI
R.THAMBAL
BRINDHA
SRIDEVI
LAKSHMI
PARVATHI
KAVITHA
DHANALAKSHMI
KANAGAMANI
SELVARANI
SUMITRA
SRINIVASAN
MALLIKA
SIVAKAMI
MAGUDEESWARI
KOUSALYA
BACKIYAM
JAYANTHI
P.U.WATERMAN
AYAH
T.DAIS
CNW
VOLN
CNW
VOLN
CNW
VOLN
AYAH
VOLN
CNW
VOLN
AYAH
VOLN
CNW
VOLN
AYAH
VOLN
2013 / Feb 2013
Name of local influencers

Eswaran - President
Saminathan - Member
Eswaran - Member
Punitha Saravanan - President
Subramani - Member
Veerammal - President
Saminathan - Member
Manthirachalamoorthy - President
Eswaran - Member

Kamalam - President
Kaveriyappan - Member
Jotheeswaran - Member
Jayakumar - President
Saravanakumar - Member

David - President
Subramani - Member
Muthukumarasamy - President
Shanmugam - Member
Gandhi - President

Punitha Saravanan - President
Rajendran - Member
Ganeshan - Ward Member
Shajagan - Member
Natarajan - Rotary
Boopathi - RTd Block Health Statiscian

Tmt.Selvi - President
Punitha - President
Subbarao - Counciller
Kumarasamy - Vice President
Sekar - President
IPPI 2013
Form 4A
House to House (H-to-H) Planning

Name of PHC / UHP / Mpty:________________________________________
Name of Supervisor : __________________________
Team
Number
st
H-to-H 1 day
(Monday)
Name of team members
nd
Addl. Days if required
H-to-H 2 day
(Tuesday)
Description of area to be
covered
Name & Address of first house
owner with landmark
Name & Address of last house
owner with landmark
No. of houses in the area
covered
owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
* HRA (High Risk Area) include urban slums, peri-urban areas, pavement dwellers, migrant population, hilly & tribal areas, fishermen colonies,
RI coverage <80%
Is it HRA*?
Write Y/N
IPPI 2013
Form 4C
Transit Point Planning

Name and Address of
Transit Point
Timing of the shift
Shift 1
Shift 2
Addl. Shift if required
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
IPPI 2013
Daily Miking Form
Round: Jan 2013 / F

Name of HUD / Corporation : _Tiruppur Palladam Block __________________
Name of PHC / UHP / Mpty:____Puliampatty _____________________
S. No.
Description of the area to be covered
Name of person monitoring miking
Muthandipalay
K.Ayyampalayam Vellappagounda am,
Chiniyagoudampal mpalayam,Anup karadivavi
ayam ( Selvi HI)
atty ( Selvi HI) (Selvi HI)
Karadivavi
Pudur,
Mallegoudamp Uthukuli,
alayam (Selvi Aarakulam
HI)
(Selvi HI)
8am To 12pm
Vadugapalayam
Pudur, Agrahara
Street ( Jayaram
HI)
8am To 12pm
Patchapalayam,
Vinayakar Kovil,
Kamaraj Nagar (
Jayaram Hi)
8am To 12pm
Mangalam
Road JKJ
Colony (
Jayaram HI)
8am
To 12pm
Chittambalam
a,
Chinnavaduga
palayam ,
Aluthupalaya
8am To 12pm
Pulliyappamp
alayam,
Panapalayam (
Jayaram HI)
1pm to 3pm
1pm to 3pm
1pm to 3pm
1pm to 3pm
1pm to 3pm
Time
Time
Time
Form 5
HP / Mpty:____Puliampatty ____________________________________
he area to be covered
IPPI 2013
Form 6
Checklist for Preparing / Reviewing Microplans

Name of HUD / Corp.:_Tirupur Palladam Block __________________ Name of PHC / UHP / Mpty:__Puliampatti
Date: _____/_____/_____
MICRO PLANNING CHECKLIST
Has data and feedback from past rounds been analyzed for corrective actions this round ?
YES
Yes
Brick kilns, construction sites, periurban areas, slums, recently developed townships included in
microplans
Yes
High risk and hard to reach areas identified and special plans developed to cover these areas
Booth locations identified and mapped for all areas
Have reliable and motivated vaccinators been identified and assigned booths?
Well defined day-wise area allocation to house to house teams with boundaries
Yes
Yes
Yes
Yes
At least one female vaccinator from the local community part of each house to house team
Yes
Are ICDS workers part of vaccination teams in their areas ?
Yes
Is the daily workload distribution of house to house teams reasonable (in terms of houses and
geography)
Yes
Have microplans been developed for development of transit and Mobile teams?
Yes
Supervisors identified and assigned booth/house to house/transit/mobile teams

Is there an orientation plan for vaccinators and supervisors ?
MAPS
Yes
Yes
Is Map of PHC/UHP with essential information marked?

Supervisor's map with day-wise demarcation of area to be covered by each team
Team wise maps with demarcation of area to be covered daily by each vaccinator team
VACCINE, COLD CHAIN AND OTHER LOGISTICS
yes
yes
yes
Is total OPV doses and vials required calculated correctly?

Cold chain equipment identified (required, available, functioning)
Yes
Yes
Plan for freezing of ice packs/ identification of ice pack freezing sites / ice source
Yes
Vaccine distribution centers/ dropping points identified and day wise distribution plan developed Yes
Plan for procurement of logistics and other supplies marker pens, chalk, tally sheets, etc
TRANSPORT
Yes
List of available and required vehicles

Arrangements made for the procurement / hiring of vehicles
Transport arrangement for supply of vaccine and logistics
Transport arrangement for mobile teams
Transport availability for each supervisor
Yes
Yes
Yes
Yes
Yes
Daily vehicle movement / route chart prepared for each vehicle for vaccine delivery / supervision
SOCIAL MOBILIZATION
Yes
IEC plan through mike announcements, inter-personal communication and cable TV

Plans for briefing media (District and state level)
SCHEDULE
Yes
Yes
Plan for Dist. co-ordination meeting
Yes
Schedule for district level officials to visit PHC / UHP to oversee preparations and monitor
Yes
Work plan with time-line, activities and person responsible
Yes
NO
IPPI 2013
Form 7
Supervisor's Checklist for Supervising Booth Activity
Name of HUD / Corp.:_______________________ Name of PHC / UHP / Mpty:___________________________
Name of Supervisor: ______________________________

Booth Number
Booth Location
Note : Write Y (Yes) or N (No) answer to each question

Is the booth situated in a strategic place ?
Does the booth have an IEC material (like banner) displayed prominently ?
Have all team members reported to work ? If no, arrange for replacement
Does the team clear on the work they are supposed to do today ?
Does the team have sufficient OPV vials? If no, arrange to supply.
Does the team have sufficient vaccine carrier, frozen ice packs, ice ? If no, arrange to supply
Does the team have sufficient tally sheets? If no, arrange to supply
Are there any exceptionally long queues at the booth ?
Is the team administering OPV drops to all children below five years of age ?
Is the team removing one vial at a time from vaccine carrier and keeping the carrier lid closed ?
Does the team have correct knowledge about VVM ?
Is the team reading VVM before administering OPV ?
Do they have any vaccine with VVM in Stage 3 or 4 ? If yes, remove and give replacement
Is the vaccine carrier and the currently used OPV vial protected from sunlight?
Is the team marking the left little finger of the children correctly ?
Is the team marking the tally sheet correctly after immunizing each child
Are the team members / volunteers mobilizing children from the community to the booth ?
Are the Team members / volunteers proactively seeking children walking past the booths ?
Corrective actions taken
Comments
Y/N
Y/N
Y/N
Y/N
Y/N
IPPI 2013
Form 7A
Supervisor's 'P' sweep tally sheet

Name of HUD / Corp.:___________________ Name of PHC / UHP / Mpty:_____________________
Name of Supervisor: ______________________
Supervisor shall check and immunize any 0-5 years old child found un-immunized outside houses in their
team areas. Put a tally mark for each child.
No. of children checked outside houses in team
areas
No. of children found un-immunized outside
houses in team areas
No. of children immunized by supervisor today
outside houses in team areas
Supervisor shall visit every 10th 'P' marked house and immunize any missed child by the vaccination teams
Name of village / Urban area : _______________________
No. of house visited
No. of children found immunized by supervisor
Less than 2 years
2-5 years of age
No. of children detected un-immunized by supervisor
Less than 2 years
2-5 years of age
Less than 2 years
2-5 years of age
Team number:
Total

Less than 2 years
2-5 years of age
Less than 2 years
2-5 years of age
Less than 2 years
2-5 years of age
Team number:
Total

Less than 2 years
2-5 years of age
Less than 2 years
2-5 years of age
Less than 2 years
2-5 years of age
Team number:
Total
Total No. of houses checked by supervisor
Number of OPV vials used by supervisor
Total No. of P houses with unimmunized children detected by supervisor

Total No. of 0-5 years children immunized by supervisor today in houses
Form 7A
Form 8
IPPI 2013
Tally sheet for Booth/ Transit point

Date : ___________
Name of PHC / UHP / Mpty._____________________ Name of Village / Urban Area:_______________________

Number of children above
5 years immunized
Name of Supervisor: ________________________

Team No.: _____
Note :
Name of team members: 1)______________________2)__________________

1
10
(2) Conitnue in the next sheet, if required
11
12
13
14
15
(3) Mark a in the appropriate square for each child immunized
16
17
18
19
20
21
22
23
24
25
27
28
29
30
3)______________________4)__________________
(1) Use fresh tally sheet for each day
Number of children below 5 years immunized

1
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Total
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
OPV Vials
101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125
126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150
Full
151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175
176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200
201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225
Partially
Used
226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250
Empty
251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300
Total Number of children under 5 years immunized :
Signature of team members
Signature of supervisor
Received
Returned
IPPI 2013
Form: 8 A
Tally Sheet for House to House activity

Name of Supervisor: ______________________
Please use one fresh tally sheet for each day
Village / Urban Area: ______________________________________________________
PHC / UHP :______________________
Name of team member
1 _____________________2 _________________
Date: _______________
Team No.: _________
Teams should make an active effort to immunize children outside houses while doing house-to-house activity. Put a tally
mark for each child immunized outside houses.
Total
No. of children immunized in streets

No.of children immunized in schools/ playgrounds /
fields
Total number of children immunized outside houses
After visiting the houses enter the no. of children immunized under the square for that house. If any child in the house has
not received OPV doses and is left unimmunized or house is locked, mark a 'X' along the house number
Name and address of first house owner with landmarks:

Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
Total
1
9 10 11 12 13 14
15 16 17 18
19 20 21 22 23 24 25 26 27 28
29 30 31 32
33 34 35 36 37 38 39 40 41 42
43 44 45 46
47 48 49 50 51 52 53 54 55 56
57 58 59 60
61 62 63 64 65 66 67 68 69 70
71 72 73 74
75 76 77 78 79 80 81 82 83 84
85 86 87 88
89 90 91 92 93 94 95 96 97 98
99 100 101 102 103 104 105 106 107 108 109 110 111 112
113 114 115 116 117 118 119 120 121 122 123 124 125 126
Name and address of last house owner with landmarks:

Total
Number of houses visited
Number of children immunized in houses
Number of children immunized outside houses
OPV vials
Received
Returned
Full
Partially used
Empty
Signature of team members 1.__________ 2. ___________ Signature of supervisor __________ Signature of MO i/c:_________________
Form 8 B
IPPI 2013
X Marked Houses Information Form

Team No.
Name of PHC / UHP / Mpty.:________________________________

House
Number
Name of Family Head
Address of X Marked Houses
Village / Urban area:___________________

Reason for X Mark
Date House
converted from
X to P
No. of
children
immunized
Total
(1)
No. of children
vaccinated outside
houses by teams
(2)
(3)
(4)
No. of 'P' Houses with

unvaccinated children
detected by supervisor
No. of children
vaccinated in 'P'
houses by
supervisor
Total Children
Vaccinated
Daily Supervisor Reporting Form
Day: 1 / 2 / 3 / 4 / 5 / 6 / 7
(6)
(7)
(8)
(1+2+3+4+5+6+7+8)
Total OPV vials used
No. of children
vaccinated at Migrant
sites
(5)
No.of Children
vaccinated at transit
points
House to House Coverage

No. of children
vaccinated outside
houses by Supervisor
Supervisor's Name:__________________________
checked by supervisor
Name of HUD / Corporation:____________________________________
No. of 'P' Houses
No. of 'X' houses left at

the end of the activity
No. of children
vaccinated in 'X'
houses
No. of 'X' houses

converted to 'P'
Booth
Coverage
No. of 'X' houses

generated by teams
No. of children
vaccinated in
houses by teams
Total houses visited by

teams
Total Children
Vaccinated in
booths
Team No./ Booth No.
S.No.
IPPI 2013
Form 9

Name of PHC /UHP / Mpty:_________________________
Date:____/____/___
Total
No. of children vaccinated
outside houses by teams
(2)
(3)
(4)
Total Children Vaccinated
Daily PHC / UHP / Mpty Reporting Form
Day: 1 / 2 / 3 / 4 / 5 / 6 / 7
(6)
(7)
(8)
(1+2+3+4+5+6+7+8)
No. of children vaccinated at

Migrant sites
(5)
No.of Children vaccinated at transit

points

No. of children vaccinated outside
houses by Supervisor
'P' houses by supervisor
No. of children vaccinated in
unvaccinated children detected

by supervisor
supervisor
No. of 'P' Houses checked by
of the activity
No. of 'X' houses left at the end

'X' houses
'P'
No. of 'X' houses converted to
Booth
Coverage
teams
No. of 'X' houses generated by

houses by teams
(1)
Total houses visited by teams
Total Children Vaccinated in

booths
Name of Supervisor
S.No.
IPPI 2013
Form 9A

Date:____/____/___
Total
(1)
outside of houses by
teams
(2)
(3)
(4)
No.of Children vaccinated at

transit points

Migrant sites
Daily HUD / Corporation Reporting Form

Day: 1 / 2 / 3 / 4 / 5 / 6 / 7
(5)
(6)
(7)
(8)
(1+2+3+4+5+6+7+8)

outside houses by Supervisor

in 'P' houses by
supervisor
HUD / Corporation:______________________________________

No. of 'P' Houses checked

by supervisor
No. of 'X' houses left at the

end of the activity

in 'X' houses
No. of 'X' houses converted

to 'P'
Booth
Coverage
No. of 'X' houses generated

by teams

in houses by teams
Total houses visited by teams

in booths
Name of PHC / Mpty
S.No.
IPPI 2013
Form 9B
Date:____/____/___
Total
No. of children
vaccinated outside
houses by teams
(2)
(3)
(4)

Migrant sites
HUD / Corporation:______________________________________
(6)
(7)
(8)
(1+2+3+4+5+6+7+8)
No.of Children vaccinated at

transit points

outside houses by Supervisor
(5)
by supervisor
No. of children
vaccinated in 'P' houses
by supervisor
No. of 'P' Houses checked
end of the activity
No. of 'X' houses left at the
No. of children
vaccinated in 'X' houses
converted to 'P'
No. of 'X' houses
Booth
Coverage
generated by teams
No. of 'X' houses
No. of children
vaccinated in houses by
teams
(1)
Total houses visited by
teams
Total Children
Vaccinated in booths
Day Number
IPPI 2013
Form 10
Consolidated HUD / Corporation Reporting Form
Date:____/____/___
OPV UTILISATION REPORT

IPPI Jan 2013 / Feb 2013
Name of HUD:_______________________________
Opening Balance before PPI round (Date:____/____/____)
Peripheral Level :
Stock at HUD :
Total
OPV Utilisation
OPV Coverage
Wastage
Total
Closing Balance at the end of PPI Round (Date: ___/___/___)
Peripheral Level
Stock at HUD
Total
Signature of DDHS

IPPI Forms - 2013

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IPPI Forms - 2013

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IPPI 2013

Manpower Planning Form

Name of HUD / Corporation : ___Tirupur HUD Palladam Block Phc: Puliampatti____________________________________

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

No. of Supervisors required

Round: Jan 2013 / Feb 2013

Vaccine and Cold Chain Planning Form

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 : _Tirupur HUD Palladam Block Phc: Puliampatti__________________________________

Transport for mobile

Transport for supply of

Indelible Marker Pen

P sweep tally sheet

Name of PHC / UHP / Mpty

Name of HUD / Corporation : Tirupur HUD Palladam Block Phc: Puliampatti___________________________________________

Name of Team Members

Name of local influencer/s

Booth planning template

Round: January 2013

Name of Team Members

Name of local influencer/s

VHN (VILLAGE HEALTH

Booth planning template

Round: January 2013

Name of Team Members

Name of local influencer/s

Booth planning template

Round: January 2013

Name of Team Members

Name of local influencer/s

Booth planning template

Name of HUD / PHC / Urban Area:Tirupur / Puliyampatti

Round: January 2013

Name of Team Members

Name of local influencer/s

Booth planning template

Round: January 2013

Name of Team Members

Name of local influencer/s

2013 / Feb 2013

Name of local influencers

Punitha Saravanan - President

Name of local influencers

Name of local influencers

Name of local influencers

Name of local influencers

Ganeshan - Ward Member

Boopathi - RTd Block Health Statiscian

Name of local influencers

Name of HUD / Corporation : _Tirupur HUD Palladam Block Phc: Puliampatti__________________________________

Name of PHC / UHP / Mpty:Puliampatty _________________

Name of HUD / Corp.:_ Name of PHC / UHP / Mpty:_____

Name of PHC / UHP / Mpty._ Name of Village / Urban Area:___

Name of team members: 1)____2)