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
Mobile teams

Total

puliampatti

kamanaikanpalayam

krishnapuram

Total
rural

veppankottai palayam
Yes / No

Available for vaccine carriers and

cold boxes

Functioning
Required for vaccine carriers and
cold boxes

Deep freezer

Yes / No

Cold boxes

ILR

Vaccine carriers

Available

Name of HUD / Corporation : _____ TIRUPPUR

Required

Available

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 PHC / UHP / Mpty

IPPI 2013

Form 2

Vaccine and Cold Chain Planning Form

HSC.PULIAMPATTI
Round: Jan 2014 / Feb 2014

Ice packs

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

Name of HUD / Corporation : _______________________________________

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

Chalk

Logistics for
Supervisors

Vaccinator tally sheets

Reporting formats

P sweep tally sheet

Check lists

Name of PHC / UHP / Mpty

IPPI 2013
Form 3

Logistics and Transport Planning Form

Round: Jan 2014 / Feb 2014

Transport for supervision

IPPI 2013

Form 4

Booth Planning

Round

Name of HUD / Corporation : TIRUPUR

Booth Number

Name of PHC / UHP / Mpty: PULIYAMPATTI

Booth Location

PULIYAMPATTI
669

670

671

672

PHC

VEPPANKUTTI PALAYAM .SCHOOL

KAMANAIKAN PALAYAM

K.KRISHNAPURAM

Name of Team Members

Designation

SUGUNADEVI

VHN

PARWATHI

AYAH

RAJESWARI

AWW

PRABHAKARAN

VOLN

DHANALAKSMI

AYAH

KARTHI

VOLN

BALAN

TEACHER

RAVI

VOLN

SOROJA

AWW

ESWARI

AYAH

SUDHA

VOLN

KALAIVANI

AWW

RADHAMANI

AWW

AMIRTHAM

VOLN

MANIMEGALAI

AYAH

RAVI

VOLN

Round: Jan 2014 / Feb 2014

IPPI 2015

Form 4A

House to House (H-to-H) Planning

Round: Jan 2015 / Feb 2015

Name of HUD / Corporation : Tirupur

Name of PHC / UHP / Mpty: Puliyampatti

Name of Supervisor : Dr.Sampoornam

Addl. Days if required
Team
Number
669

H-to-H 1st day

(Monday)

Name of team members

SUGUNADEVI.VHN,PARWATHI Description of area to be
covered

west st

east st

Name & Address of first house

owner with landmark

manokaran

5/12 muthu

Name & Address of last house

owner with landmark

palanisami

perumal

No. of houses in the area

rajeswari,,prabhakaran

150

dhanalaksmi.,karthi

annanagar

field huts

Name & Address of first house

owner with landmark

saraswathi

chandiran

Name & Address of last house

owner with landmark

maruthamuthu

kutti
168

vinayakar koil st field huts

Name & Address of first house

owner with landmark

muthukumar

velu sami

Name & Address of last house

owner with landmark

shanthamani

natarai
30

,saroja,eswari

30

Description of area to be
covered

kallimedu

saralai thottam

Name & Address of first house

owner with landmark

kumar

mayil sami

Name & Address of last house

owner with landmark

vanchi muthu

kalliyan

No. of houses in the area

671

100

Description of area to be
covered

No. of houses in the area

balan, ravi

100

Description of area to be
covered

No. of houses in the area

670

H-to-H 2nd day

(Tuesday)

Description of area to be
covered

15
school st

15
mariyamman koil
st

Is it HRA*?

Write Y/N

671

,saroja,eswari

kalaivani,sudha

672

radhamani,amirtham

manimegalai,ravi

Name & Address of first house

owner with landmark

ramasami

marappan

Name & Address of last house

owner with landmark
No. of houses in the area
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
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
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

eswari

murugasami
200

200

south adst

north adst

manokaran

ravichandiran

saraswathi

pappan
150

159

panyath office

murugan koil

raju mani

nataraj

eawaram

muthammal

99
101
madurai veeran amman koil st
koil st
prama
ganeshan
velingiri

dhavasi
50

60

NID/ SNID

Form: 4B

Template for House to House Planning

District: ___________________

Block/Urban Area: _____________________

Name & Mobile no of Supervisor: ____________________________________

Planning Unit: ________________

Round: _____________________

Designation: _____________________ Name and Mobile no of MO I/C______________________________

Name of Vaccinator
Day 1

Day 2

Day 3

Day 4

Yes / No

Yes / No

Yes / No

Yes / No

Name & description of area to be

covered
Designation

Is this an identified HRA?

If yes, type of area

Mobile No

Name & address of 1st house owner

with land mark
Via

Name of Vaccinator

Via

Urban slum/ Nomads/

Urban slum/ Nomads/

Urban slum/ Nomads/

Urban slum/ Nomads/

Brick kiln/ Construction site

Others/ Settled HRA

Brick kiln/ Construction site Others/

Settled HRA

Brick kiln/ Construction site Others/ Brick kiln/ Construction

Settled HRA
site Others/ Settled HRA

Designation

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

Signature of Medical Officer

______________

_____________
Day 5

Yes / No
Urban slum/ Nomads/
Brick kiln/ Construction
site Others/ Settled HRA

e 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

Day 1

Type of site
Is this site linked to RI
session site

Planning Unit:

Site 1

Site 2

Yes / No

Yes / No

Nomad / Brick Kiln /

Construct Site /Other

Nomad / Brick Kiln /

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

Day 2

If yes, type of site

Is this site linked to RI
session site

Yes / No

Yes / No

Nomad / Brick Kiln /

Construct Site /Other

Nomad / Brick Kiln /

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

Day 3
Name of Sub Center
Name of ANM
RI session site
Day of RI session
Supporting ASHA/ Link worker/ mobilizer

If yes, type of site

Is this site linked to RI
session site

Supervisor (Name & Tel No): _______________

Yes / No

Yes / No

Nomad / Brick Kiln /

Construct Site /Other

Nomad / Brick Kiln /

Construct Site
/Other

Yes / No
Yes / No
Site specific Routine Immunization Information

AWW supporting session

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:

Name & Tel No): ______________________

Site 3

Site 4

Yes / No

Yes / No

Nomad / Brick Kiln /

Construct Site /Other

Nomad/ Brick Kiln/

Construct Site /Other

Yes / No
munization Information

Yes / No

Yes / No

Yes / No

Nomad / Brick Kiln /

Construct Site /Other

Nomad/ Brick Kiln/

Construct Site /Other

Yes / No
munization Information

Yes / No

Yes / No

Yes / No

Nomad / Brick Kiln /

Construct Site /Other

Nomad / Brick Kiln /

Construct Site /Other

Yes / No
munization Information

Yes / No

ow of Timing of visit.

IPPI 2015

Form 4C

Transit Point Planning

Round: Jan 2015 / Feb 2015

Name of HUD / Corporation : ___________________

Name and Address of
Transit Point

Shift 1
Timing of the shift
Name of Team Members

Name of Supervisor
Timing of the shift
Name of Team Members

Name of Supervisor
Timing of the shift
Name of Team Members

Name of Supervisor
Timing of the shift
Name of Team Members

Name of PHC / UHP / Mpty:________________________________________

Shift 2

Addl. Shift if required

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

an 2015 / Feb 2015

IPPI 2013

Form 5

Daily Miking Form

Round: Jan 2014 / Feb 20

Name of HUD / Corporation : ___________________

S. No.

Name of PHC / UHP / Mpty:________________________________________

Description of the area to be covered

Time

Name of person monitoring miking

Time

Name of person monitoring miking

Time

Name of person monitoring miking

Round: Jan 2014 / Feb 2014