FORM 1: HEALTH CENTER WORK PLAN FOR REACHING EVERY PUROK EVERY QUARTER

Name of RHU/BHS: ________________________________

Date of Completion: _____________________

Name of Midwife: _______________________

Name of BHW: __________________________

QUARTER 1

Barangay
Name

Purok
Name

Result of
previous card
checks
(HR/LR/ND*)

Date for
master
listing

Dates for catch up

Jan

Feb

Mar

Date for
Results of
Date for
next door to latest card
master
door card
check
listing
check
(HR,LR, ND)

QUARTER 2
Dates for catch up
Apr

May

Jun

QUARTER 2
Date for next
door to door
card check

Results of latest
card check
(HR,LR, ND)

FORM 1: HEALTH CENTER WORK PLAN FOR REACHING EVERY PUROK EVERY QUARTER
Name of RHU/BHS: ________________________________

Date of Completion: _____________________

Name of Midwife: _______________________

Name of BHW: __________________________

QUARTER 3

Barangay
Name

Purok
Name

Result of
previous card
checks
(HR/LR/ND*)

Date for
master
listing

Dates for catch up

Jul

Aug

Sep

Date for
Results of
Date for
next door to latest card
master
door card
check
listing
check
(HR,LR, ND)

QUARTER 4
Dates for catch up
Oct

Nov

Dec

QUARTER 4
Date for next
door to door
card check

Results of latest
card check
(HR,LR, ND)

Form 2: MASTERLIST OF CHILDREN (0-23 MONTHS OLD)

TT2

MMR

AMV

OPV 3

OPV 2

OPV 1

Penta
3

Detailed address
in Purok including
landmarks

Penta
2

Name of
Mother

Penta
1

Birthday

HepB
BD

Age

Place if mot
dose

Place if vaccine has been given

BCG

Name of Child

Name of Midwife: _____________________________

Name of BHW: ________________________________
Date of Completion: ____________________________

TT1

Name of RHU/BHS: ____________________________________________

Name of Barangay: _____________________________________________
Name of Purok: ________________________________________________

TT5

TT4

TT3

if mother recall TT
doses
Remarks

Form 4: QUARTERLY CARD CHECK IN HIGH RISK PUROK TO MEASURE RISK STATUS I
Method: DOOR TO DOOR VISITS FOR CHILDREN AGED 12 TO 23 MONTHS
BHS Name: ____________________

Barangay Name: _________________________

Purok Name: _______________________

Door
No.

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

Date: _____

Health Worker Name: _______________________

Immunity Gap Card Check (12 to 23 months)

No. of
No. of Partially
Completely
Immunized
Immunized
No. of Children
No. of
aged between
children
12-23 months
with card (3 doses of Penta (Any one dose of
plus MCV1 and
Penta or MCV
MCV2)
missed)

ASURE RISK STATUS IN ONE PUROK

3 MONTHS

__________

Date: __________

__________________

onths)

No. of Children
with
No Card
No. with zero
(Write name
dose
of child with zero
dose and no card
(Card shows no on the back of this
doses received) form and check in
TCL)

FORM 5: CONSOLIDATED MONITORING OF QUARTERLY CARD CHECKING IN HIGH RISK PUROKS

Health Center Name: _________________________

Barangay Name: ______________________________

Date: ______________

Results of Card Checks

Name of High Risk
Purok

Date of
No. of
No.
No. of
No. of
%
Decision
Card No. of
Children
with no. with
Children
Completely
Partially
Completely
on High or
Check
with
zero No Card
Checked
Immunized Immunized
Immunized Low Risk
Card
dose

% of Completely Immunized - In puroks where most children have cards:

Number of children with complete immunization X 100
Total number of children with cards
High Risk Purok: <90% of children had complete immunization

%
Decision
Children
on High or
without
Low Risk
Cards

Children without cards - In puroks where a significant number of children do not have cards:
Number of children without cards X 100
Total number of children checked
High Risk Purok: 80% of children aged 12 to 23 months are without cards

% of Completely Immunized - In puroks where most children have cards:

Number of children with complete immunization X 100
Total number of children with cards
High Risk Purok: <90% of children had complete immunization

Children without cards - In puroks where a significant number of children do not have cards:
Number of children without cards X 100
Total number of children checked
High Risk Purok: 80% of children aged 12 to 23 months are without cards

Result of Catch UP
Date Catch
No. Penta
Up Done
No. MCV
Dose
for High
Given
Given
Risk Purok

t have cards:

t have cards:

FORM 6: QUARTERLY SUPERVISORY CHECKLIST

Name of Health Center: ________________________
Name of Supervisor: ___________________________

COMMUNICATION

AEFI

COLD CHAIN,
LOGISTICS AND
SUPPLY

SURVEIL
LANCE

MONITORING

SERVICE DELIVERY

Component

What to check

Check TCL

Date: _________________

What to look for

TCL updated and complete
TCL showing unimmunized gaps
Lists of names for follow up doses

HC maps showing barangays

Barangays listed with population of
each
Lists of population
Names of puroks listed
High Risk Puroks identified
Outreach sessions planned and
Session Plan
monitored
Chart up to date
Monitoring Chart
Magnitude of drop outs displayed
Quarterly card checking planned and
Card Checking in HR monitored
puroks
Results of card check documented
Map

Low performing
Barangays
Reports of
suspected VPDs
Case Investigation
Check Refrigerator

Coverage by Barangay recorded

Low performers investigated by review
of TCL
Suspected cases reported and
investigated on time
Case investigation forms available in
HC
Ref. functioning, if not has report been
made and follow up

Temperature
monitoring

Temperature record twice per day

Check vaccine
supply

Vaccine log book in use

Any stock out/over stock

Expired vaccines

Any expired vaccines discarded last &

current year (if yes: write the name of
vaccine and quantity)

Immunization
Safety

Any prefilling or re-capping of syringes

Poster with national Immunization Schedule Poster

schedule
displayed
Mothers correctly informed about next
Mothers knowledge
dose/visit

COMMUNICATIO
PLANNING
AND
SUPERVISI
ON

Names and phone

numbers of BHWs

Directory of BHWs names and phone

numbers

Fixed and outreach sessions schedule

displayed for public
Microplan shows activities for high risk
Microplan available
puroks
Supervisory plan
Schedule of supervisory visits
Supervisory log
Action taken from previous visits
book
Session plan
displayed

_
Enter YES or
NO

Comment

FORM 7: MANAGING AND MONITORING VACCINE SUPPLY

Name of Health Cneter: ________________________________
Item
Eligible Pop (EP): Total
Population x 2.7%

Name of Monitor: __________________________

Record the following using the Vaccine Stock Card

Monthly
Needs

If expiry date is not available in the stock

register, then write NA in the relevant column

Total vials

BCG (20-dose per vial)

(EP x 1 dose x 2.5/20/12 )
HEP B (10-dose/vial)
(EP x 1 dose x 1.1/10/12 )
PENTA (1-dose/vial)
(EP x 3 doses x 1.1/12 )
OPV (20-dose/vial)
(EP x 3 doses x 1.67 /20/12)
MEASLES (10-dose/vial)
(EP x 1 dose x 2/10/12)
MMR (5-dose per vial)
(EP x 1 dose x 1.1/5/12 )
PCV (1-dose/vial)

Expiry Date

Date completed: ________________

Write the actual number and other inform

indicated of the vaccines available in the hea

Total

Vials

(EP x 3 doses x 1.1/1/12 )

ROTAVIRUS (1-dose/vial)
(EP x 2 doses x 1.1/1/12 )
TT (20-dose/vial)
(EP x 2 doses x 1.67 /20/12)

te completed: ________________

the actual number and other information

of the vaccines available in the health facility

Expiry Dates

Status of VVM
(1,2,3,4)

Calculate the number of months of

available stock.
Divide total vials counted by the
calculated monthly or quarterly needs.

Total No. of Months

Overstock (OS),
Understock (US),
Stockout (SO),
Optimum (O)

FORM 8: QUARTERLY RHU/ HC COVERAGE MONITORING

Name of RHU/HC: __________________________________

Barangay Name

Total Pop.

Quarter Monitored: 1stQ (

2ndQ (

) 3rdQ (

) 4thQ (

) Name of Monitor: ______________________

Immunization Coverage (%)

Target Pop. ( < 1

year )

Un-immunized (No.)

No. of Doses of Vaccines Administered

(D/C*100)

(E/C*100)

(F/C*100)

(G/C*100)

C-E

C-F

No. of Measles
Cases

No.

No.

PENTA1

PENTA3

MCV1

MCV2

PENTA1

PENTA3

MCV1

MCV2

PENTA3

MCV1

CRUZ

2010

54

20

18

37%

33%

14%

36

46

CURVA

3642

98

51

43

19

52%

44%

19%

55

79

KAINGIN

2983

81

48

48

19

59%

59%

23%

33

62

LUSOK

2200

59

10%

10%

2%

53

58

Date: _

___

Date: __________________
Drop-out Rates (%)

Identify Problems

(D-E)/D*100

(D-F)/D*100

Good=if H is 95%
above

Good= if P is between
-5 to 10

PENTA1-PENTA3

PENTA1-MCV1

Access

Utili-zation

10%

60%

Poor

Good

16%

63%

Poor

Good

60%

Poor

Good

83%

Poor

Good

Priority Area