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

[Link]

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

[Link]

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 PHC / UHP / Mpty

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

Round: Jan 2013 / Feb 2013

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

[Link] 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 PHC / UHP / Mpty

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

Round: Jan 2013 / Feb 2013

2W

IPPI 2013

Form 4

Booth Planning
Round: Jan 2013 / Feb 2013
Name of HUD / Corporation : ___________________

Booth Number

Booth Location

Name of Team Members

664
RANGASAMUDTHIRAM-HSC

665

[Link]

666

[Link]
[Link]

667

[Link]

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
[Link]
SIVASHANKAR
PALANIYAMMAL
RAVI

Name of local influencer/s

[Link]
AYYA
VOL
VOL
[Link]
AYYA
AYYA
VOL
CNW
AYAH
CNW
AYAH
CNW
[Link]
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

Name of Team Members

Name of local influencer/s

669

670

671

672

[Link]
LAKSHMI
[Link]
MOHANA
PULIAMPATTI-HSE
KATHIRAVAN
SUBRAMANI
RANGATHAL
VEPPANKOTTAIPALAYAM-P.U SCHOOL DHANALAKSHMI
SAROJA
SUDHA
DHANDAPANI
[Link] ESWARI
RADHA MANI
AMIRTHAM
RAJA
MANIMAGALAI
[Link]

VHN (VILLAGE HEALTH

NURSE)
VOL
CNW - AYAH
VOL
TEACHER
TEACHER
[Link]
[Link]
CNW
VOL
[Link]
[Link]
CNW
VOL
VOL
CNC AYAH

NID/SNID

Form 4 A

Booth planning template

Name of HUD / PHC / Urban Area:Tirupur / Puliyampatti
Name of Supervisor: Boopathy, B/S
Booth Number

Booth Location

673
[Link]-NMC

674

CHINNIAGOUNDAMPALAYAM

675

VELAPPAGOUNDAPALAYAM
[Link]

676

ANNUPATTI [Link]

Round: January 2013

Name of Team Members

[Link]
SHANTHAMANI
PIRIYA
SUDHAKAR
SHANTHI
GOMATHI
NEELAVATHY
RAMATHAL
JOTHIMUTHU
KALIAMMAL
VASANTHAMANI
RAMASAMY
AMARAVATHY

Name of local influencer/s

VHN
[Link]
VOL
VOL
C,N.W
[Link]
[Link]
[Link]
VOL
[Link]
[Link]
VOL
CNW

676

677

JEYALAKSHMI
RAJESHWARI
RATHINAL
ANNUPATTI [Link]
SELVI
KANNAMMAL
MUTHULAKSHMI
MUTHANDIPALAYAM P.U. [Link] ANITHA

N.M..AYYAH
VOL
[Link]
CNW
[Link]
[Link]
VOL

NID/SNID

Form 4 A

Booth planning template

Name of HUD / PHC / Urban Area:Tirupur / Puliyampatti
Name of Supervisor: [Link], Food Inspector
Booth Number

678

679

680

681

682

Booth Location

Round: January 2013

Name of Team Members

[Link]
MANIKAM
LAKSHMI
PARVATHY
KARADIVAVI HSC
RANJIM
LAKSHMI
JANAKI
MAIAMMAL
KARADIVAVI PUDUR-SCHOOL
MARAGATHAL
SIVAKAMI
RAJATHI
MALLAIGOUNDAMPALAYAM-SCHOOL RAGAMMAL
SARSWATHI
MALARKODI
SELVI
CHITRA
[Link]-SCHOOL
ANGATHAL
AMARAWATHY
NEELA
PAPALLVHN
ARAKKULAM SCHOOL

NID/SNID

Name of local influencer/s

VHN
CNW
AYYA
VOL
CNW
S.O
AYAH
AYAH
CNW
S.O
[Link]
[Link]
S.O
VOL
[Link]
AYAH
CNW
S.O
AYAH
AYAH
Form 4 A

Booth planning template

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

Name of Supervisor: Kalaiammal CHN
Booth Number

693

694

695

696

697

698

Booth Location

Round: January 2013

Name of Team Members

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
[Link]
MANI
ROTARY SCHOOL MANGALAM ROAD [ ESTHER
SASIPRIYA
MANGALAM ROAD)
YUVARANI
RAJAKUMAR
LAKSHMI
PUSHPA
JKJ COPLONY MILK SOCIETY

Name of local influencer/s

[Link]
B.W HELPER
[Link]
VOL
[Link]
B.W. ORGANISOR
VOL
[Link]
[Link]
[Link]
[Link]
VOL
[Link]
VOL
[Link]
VOL
VHN
VOL
[Link]
VOL
[Link]
VOL
[Link]
[Link]

NID/SNID

Form 4 A

Booth planning template

Name of HUD / PHC / Urban Area:Tirupur / Puliyampatti
Name of Supervisor: Kalaiammal CHN
Booth Number

Booth Location

Round: January 2013

Name of Team Members

[Link]
722
CHITTAMBALAM-HSE

Name of local influencer/s

V.H.N

722
CHITTAMBALAM-HSE

723

CHINNAVADUGAPALAYAM-SCHOOL

724

ALUTHUPALAYAM-SCHOOL

725

PILLIAPPAMPALAYAM-SCHOOL

726

PANAPALAYAM-CMNMC

[Link]
[Link]
[Link]
BRINDHA
SRIDEVI
LAKSHMI
PARVATHI
KAVITHA
DHANALAKSHMI
KANAGAMANI
SELVARANI
SUMITRA
SRINIVASAN
MALLIKA
SIVAKAMI
MAGUDEESWARI
KOUSALYA
BACKIYAM
JAYANTHI

[Link]
AYAH
[Link]
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

Name of local influencers

Veerammal - President

Saminathan - Member

Manthirachalamoorthy - President

Eswaran - Member

Name of local influencers

Kamalam - President

Kaveriyappan - Member

Jotheeswaran - Member

Jayakumar - President

Saravanakumar - Member

Name of local influencers

David - President

Subramani - Member

Muthukumarasamy - President

Shanmugam - Member

Gandhi - President

Name of local influencers

Punitha Saravanan - President

Rajendran - Member

Ganeshan - Ward Member

Shajagan - Member

Natarajan - Rotary

Boopathi - RTd Block Health Statiscian

Name of local influencers

[Link] - President

Punitha - President

Subbarao - Counciller

Kumarasamy - Vice President

Sekar - President

IPPI 2013

Form 4A

House to House (H-to-H) Planning

Round: Jan 2013 / Feb 2013
Name of HUD / Corporation : ___________________

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
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

* 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

Round: Jan 2013 / Feb 2013
Name of HUD / Corporation : ___________________
Name and Address of
Transit Point
Timing of the shift

Name of PHC / UHP / Mpty:________________________________________

Shift 1

Shift 2

Addl. Shift if required

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 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
[Link] 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

Name of person monitoring miking

Time

Name of person monitoring miking

Time

Form 5
Round: Jan 2013 / Feb 2013

HP / Mpty:____Puliampatty ____________________________________

he area to be covered

IPPI 2013

Form 6

Checklist for Preparing / Reviewing Microplans

Round: Jan 2013 / Feb 2013

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:___________________________

Round: Jan 2013 / Feb 2013

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: ______________________

Round: Jan 2013 / Feb 2013

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
No. of children immunized by supervisor today
Less than 2 years
2-5 years of age

Team number:

Total

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
No. of children immunized by supervisor today
Less than 2 years
2-5 years of age

Team number:

Total

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
No. of children immunized by supervisor today
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

Round: Jan 2013 / Feb 2013

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

Round: Jan 2013 / Feb 2013

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

[Link] 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:

No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
Total no. of children 0-5 years in the house
No. of children 0-5 years immunized at home today
No. of house visited
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.

Round: Jan 2013 / Feb 2013

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)

[Link] 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.

[Link].

IPPI 2013
Form 9

Round: Jan 2013 / Feb 2013

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)

Total OPV vials used

No. of children vaccinated at

Migrant sites

(5)

[Link] Children vaccinated at transit

points

House to House Coverage

No. of children vaccinated outside
houses by Supervisor

'P' houses by supervisor

No. of children vaccinated in

unvaccinated children detected

by supervisor

No. of 'P' Houses with

supervisor

No. of 'P' Houses checked by

of the activity

Name of HUD / Corporation : ___________________

No. of 'X' houses left at the end

No. of children vaccinated in

'X' houses

'P'

No. of 'X' houses converted to

Booth
Coverage

teams

No. of 'X' houses generated by

No. of children vaccinated in

houses by teams

(1)
Total houses visited by teams

Total Children Vaccinated in

booths

Name of Supervisor

[Link].

IPPI 2013

Form 9A

Round: Jan 2013 / Feb 2013

Name of PHC / UHP / Mpty:________________________________________

Date:____/____/___

Total
(1)
No. of children vaccinated
outside of houses by
teams

(2)
(3)
(4)

[Link] Children vaccinated at

transit points

No. of children vaccinated at

Migrant sites

Total Children Vaccinated

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)

Total OPV vials used

No. of children vaccinated

outside houses by Supervisor

House to House Coverage

No. of children vaccinated
in 'P' houses by
supervisor

HUD / Corporation:______________________________________

No. of 'P' Houses with

unvaccinated children
detected by supervisor

No. of 'P' Houses checked

by supervisor

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

Name of PHC / Mpty

[Link].

IPPI 2013

Round: Jan 2013 / Feb 2013

Form 9B

Date:____/____/___

Total
No. of children
vaccinated outside
houses by teams

(2)
(3)
(4)

No. of children vaccinated at

Migrant sites

Total Children Vaccinated

HUD / Corporation:______________________________________

(6)
(7)
(8)
(1+2+3+4+5+6+7+8)

Total OPV vials used

[Link] Children vaccinated at

transit points

House to House Coverage

No. of children vaccinated
outside houses by Supervisor

(5)

by supervisor

No. of children
vaccinated in 'P' houses

unvaccinated children
detected by supervisor

No. of 'P' Houses with

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

Round: Jan 2013 / Feb 2013

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