K Ayampalayam

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
673
674
675
676
Name of PHC / UHP / Mpty:________________________________________

PULIAMPATTI
Booth Location
K.AYAMPALAYAM
,AWC
Name of Team Members

GEETHA
AWW
SHANTHAMANI
AYAH
KISHOR
VOLN
SENTHIL
VOLN
SHANTHI
AWW
GOMATHI
S.AYAH
LEELA
VOLN
CHINNIYAGOUNDEN PALAYAM AWC SHANMUGAZHELIL
VELLAPAGOUNDEN PALAYAM
SCHOOL
ANUPATTI AWW
Designation
VOLN
DHANAN
S.O
JOTHO
VOLN
KALIMUTHU
VOLN
SIVAGAMI
VOLN
AMARAWATHI
AWW
JAYALAKSMI
AYAH
VINOTH KUMAR
VOLN
ARUCHAMI
VOLN
677
MUTHANDIPALAYAM AWC
SELVI
AWW
SASIKALA
S.O
MUTHULAKSMI
AYAH
KANNAMMAL
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
673
st
H-to-H 1 day
(Monday)
Name of team members
geetha,,kishor
Description of area to be
covered
Name & Address of first house
owner with landmark
Name & Address of last house
owner with landmark
rajeev coloni
indira coloni
narasimman
kamalanathan
velusami
monokaran
No. of houses in the area
shanthamani,,shantha
covered
owner with landmark
owner with landmark
200
674
shanthii,,gomathi
covered
owner with landmark
owner with landmark
field huts
duraisami
dhamodharan
palani
velusami
100
shanmugazhelil,,,leela
mettu st
thirumoorthi
nagaraj
bharathiraj
karuppan
100
675
Dhanam Jothi
100
adst
gounder st
punniyamoorthi
nagarai
sahnmugam
purushothaman

covered
82
adst

covered
owner with landmark
owner with landmark
200
goun st
Addl. Days if required
nd
H-to-H 2 day
(Tuesday)
100
Field Huts
52
gounder st
Is it HRA*?
Write Y/N
675
Dhanam Jothi
kalimuthu,,,sivagami

owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
covered
676
amarawathi,,arucami
Jayalakshmi
Vinothkumar
677
Selvi
Saasikala
Muthulakshmi Kannammal
owner with landmark

owner with landmark
covered
owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
covered
owner with landmark
owner with landmark
Narayanan
Krishnan
Venkatesh Babu
Nandhagopal
40
40
east st
west st
kalimuthu
nagaraj
saminathan
krishnamoorti
20
13
palaiyur
anupatti.
gounder st
senniyappan
Venkatapathi
Saminathan
Selvaraj
150
150
Kallimedu
MGR Nagar
Subramani
Selvan
Mruguan
Thirumal
150
89
Ad St
west st
Nagaraj
Muthukrishnan
Balakrishnan
Venkitupathi
50
50
Field Huts
field huts
Gopalan
Narayanan
Rangasamy
Saminathan
50
73
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

K Ayampalayam

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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:________________________________________

Name of Team Members

CHINNIYAGOUNDEN PALAYAM AWC SHANMUGAZHELIL

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

No. of houses in the area

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

owner with landmark

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

Name and mobile no of Influencer/s

Name of Sub centre

Name of ASHA/ local mobiliser/ link worker supporting RI

Template for House to House Planning

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