Escolar Documentos
Profissional Documentos
Cultura Documentos
of Supervisors required
Transit points
No. of sites to be covered
House-to-House activity
Booth activity
Urban / Rural
IPPI 2014
Form 1
Total
puliampatti
kamanaikanpalayam
krishnapuram
Total
rural
veppankottai palayam
Yes / No
Functioning
Required for vaccine carriers and
cold boxes
Deep freezer
Yes / No
Cold boxes
ILR
Vaccine carriers
Available
Required
Available
Required
Estimated population
Urban / Rural
IPPI 2013
Form 2
Ice packs
Comments (availability
of power supply,
stabilizers,
thermometers, etc.)
Total
Specify type
No. of Supervisors
Specify type
Vehicles available
Vehicles required
Specify type
Vehicles available
Other logistics
Vehicles required
Chalk
Logistics for
Supervisors
Reporting formats
Check lists
IPPI 2013
Form 3
IPPI 2013
Form 4
Booth Planning
Round
Booth Number
Booth Location
PULIYAMPATTI
669
670
671
672
PHC
KAMANAIKAN PALAYAM
K.KRISHNAPURAM
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
IPPI 2015
Form 4A
west st
east st
manokaran
5/12 muthu
palanisami
perumal
150
dhanalaksmi.,karthi
annanagar
field huts
saraswathi
chandiran
maruthamuthu
kutti
168
muthukumar
velu sami
shanthamani
natarai
30
,saroja,eswari
30
Description of area to be
covered
kallimedu
saralai thottam
kumar
mayil sami
vanchi muthu
kalliyan
100
Description of area to be
covered
100
Description of area to be
covered
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
ramasami
marappan
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
Round: _____________________
Name of Vaccinator
Day 1
Day 2
Day 3
Day 4
Yes / No
Yes / No
Yes / No
Yes / No
Name of Vaccinator
Via
Designation
Mobile No
______________
_____________
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
Yes / No
Yes / No
Site specific Routine Immunization Information
Day 2
Yes / No
Yes / No
Yes / No
Yes / No
Site specific Routine Immunization Information
Day 3
Name of Sub Center
Name of ANM
RI session site
Day of RI session
Supporting ASHA/ Link worker/ mobilizer
Yes / No
Yes / No
Yes / No
Yes / No
Site specific Routine Immunization Information
Form 4 D
Unit:
Round:
Site 3
Site 4
Yes / No
Yes / No
Yes / No
munization Information
Yes / No
Yes / No
Yes / No
Yes / No
munization Information
Yes / No
Yes / No
Yes / No
Yes / No
munization Information
Yes / No
ow of Timing of visit.
IPPI 2015
Form 4C
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
Shift 2
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
Form 5
Time
Time
Time