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KARNATAKA
TALUKA SRINIVASPUR
DISTRICT _KOLAR_______________________
SIGNATURE OF MO:
RI MICROPLANNING INDEX / CHECK LIST
Contents
3 Planning Unit Map showing Sub-Centers, Session sites, AVD and Migratory / High Risk areas
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ROUTINE IMMUNIZATION MICROPLAN - PLANNING UNIT PROFI
14. Vaccines & Vitamin A requirement per month (in doses):
1. Name of the Planning Unit _PHC RAYALPADU___________________________
2. No of Households 2531 TT BCG OPV HepB
SC ST Other Total 4 4
10. Details of Vacant Number Population Pregnant Women 0-1 yr children Condemned 0 0
subcentre 20. Status of human resources:
11. Month and year of recent migratory sites survey :15DAY.. Staf No. sanctioned
12. Month and year of recent migratory sites validation done:YES.. LHV / Supervisor 0
13. Migrant HRA sites survey data: Health worker Male 1
No. of 1 2 0 2 0
sites/areas/Village 21. NGOs Specify ___________________________________
Estimated Population 2 8 0 6800 0 22. Contact Number:
Estimated Senior HI / LHV MO D
1 2 0 1134 0
households
Estimated <1 yr 0 0 0 330 0
children
Setteled HRAs: S1 Areas with low immunization coverage found on monitoring and others; S2-Vacant / temporarily vacant
sub centres; S3 Recent outbreaks of Diphtheria, Measles other VPDs
NIT PROFILE
nth (in doses):
Penta IPV DPT MR JE Vit A
6 5 6 6 10 22
nth
_______________________
3310 27
h: __________________________
0 0
___________________
lternate Vaccine Delivery: ______________
rs)
Cold Box
V Stabilizer Cold Box 20 ltr Vaccine Carriers
5 ltr
1 0 0
0 0 0 0
0 0 0 0
0 0
0 1
0 3
0 1
0 0
_______________
MO DR ABARARPASHA.
Signature of MO
_____________ District Map Showing Taluk (Block) and Planning Unit Area____________________ RI Format-2A
RI Format-2B
Name of the Disitrict: ________________ Taluka: ____________________ Planning unit: ______________________
Planning Unit Map showing Sub-Centers, Session sites, AVD and Migratory / High Risk areas LEGEND
PHC
SUB CENTRE
VILLAGES HQ
ROAD
RAILWAY LINE
RIVER
LAKE / POND
Fixed Session F
Religious place
School S
M1 -
MIGRATORY SITES
M5
OTHERS
Signature of LHV / HA Signature of MO
RI Survey Format-S-1
Routine Immunization - Karnataka
House to House survey form
Taluk:______________________________ PHC / Planning unit :____________________________________ Subcentre: ______________________________
Name of Village/HRA sites/Urban locality:_________________________ Is this area HRA* for RI: Yes / No If HRA then type (encircle): 1 / 2 / 3 / 4 / 5 / 6 /
Persons conducting survey
1 Name:___________________________________ Designation: JHA(F) / AWW / ASHA / Link Worker / Others ___________________
2 Name:___________________________________ Designation: JHA(F) / AWW / ASHA / Link Worker / Others ___________________
Team No:________________________ Date:_____________________
Name and address of first owner with landmarks:
House Total No. of No. of No. of No. of House Total No. of No. of No. of No. of House Total No. of No. of No. of
Family Pregnant 0-1yr 1-2yr Family Pregnant 0-1yr 1-2yr Family Pregnant 0-1yr
No. No. No.
members women children children members women children children members women children
1 51 101
2 52 102
3 53 103
4 54 104
5 55 105
6 56 106
7 57 107
8 58 108
9 59 109
10 60 110
11 61 111
12 62 112
13 63 113
14 64 114
15 65 115
16 66 116
17 67 117
18 68 118
19 69 119
20 70 120
21 71 121
22 72 122
23 73 123
24 74 124
25 75 125
26 76 126
27 77 127
28 78 128
29 79 129
30 80 130
31 81 131
32 82 132
33 83 133
34 84 134
35 85 135
36 86 136
37 87 137
38 88 138
39 89 139
40 90 140
41 91 141
42 92 142
43 93 143
44 94 144
45 95 145
46 96 146
47 97 147
48 98 148
49 99 149
50 100 150
Total Total Total
Name and address of last house owner with landmarks:
Total population
* HRA: 1. Vacant sub centre 2. Areas with last three RI sessions not held 3 areas with measles Total pregnant women
outbreaks or cases of diphtheria/neonatal tetanusin last two years 4. Polio HRA 5. Low coverage
area 6. Small unvisited areas 7. Others Total < 1 yr Children
Total 1-2 yr Children
at-S-1
_____________
/5/6/7
______
______
No. of
1-2yr
children
Routine Immunization - Karnataka RI Survey Format-S-1
Signature of team members ______________ Signature of supervisor ______________ Signature of Medical Officer I/C:_________________
1
Sl. No.
11
PHC RAYALPADU
Name of Sub-Center
Population (CNA)
10995
Pregnant Women (Actual head
144
count X 2)
Target
Annual
b
Infants (Actual head count)
185
c
14
Pregnant Women (a12)
rayalpadu______________________
17
Infants (b12)
Monthly Target
28
(c X 2)
f
17
BCG (d X 1)
g
17
HepB (d X 1)
h
85
OPV (d X 5)
Name of the Disitrict: ___kolar_____________________
51
Pentavalent (d X 3)
Beneficiaries
34
IPV (d X 2)
k
17
DPT (d X 1)
l
34
MR (d X 2)
m
34
JE (d X 2)
0
n
0
o
p
Vitamin A (d X 9)
153
Beneficiaries per month for each vaccine & Vitamin A
DPT (d X 1)
q
17
school
Planning unit area - Estimation of beneficiaries, Vaccines & logistic (For Pregnancy, Primary series and Boosters)
34
TT (d X 2)
Immunization
TT (e + r X 1.11) 10
t
BCG (f X 2.0) 10
5
u
HepB (g X 1.11) 10
v
OPV (h X 1.11) 20
6
w
Pentavalent (j X 1.11) 10
x
IPV (j X 1.11) 25
y
MR ( l X 1.33 ) 10
Vaccine Vials per month
10
a1
JE (m X 1.33 ) 5
0
b1
0
c1
Vaccines and Logistics
(d X 8 X 2 ml)} X 1.11/100
Injections for outreach session per
e1
221
month= (e+f+i+j+k+l+m)
Injections for School immunization per
f1
54
month= (q + r)
55
g1
309
1.11
month
Syringes per
Planning unit: phcRI Format-12
5 ml Reconstitution
i1
27
(t + z+a1) X 1.11
Planning unit area - Village wise Routine Immunization session plan RI Format-12A
Name of the Disitrict: _____________________ Block: ________________________ Planning unit: ______________________ Sub Centre:_______________
Whether Sub centre has Full time JHA(F) encircle : Name of JHA(F) ____________________________________ Mobile No. of JHA(F): ____________________________________
Full Time / Vacant/ Temporarily Vacant
Pregnant women
HRA type (M1 -
Total number of
Site tagged to the session site Location of RI session site day & d as hard brought by Influencer with
per month
(Y / N)
injections
point
TOTAL
a b c d e f g=c+d+e+f h i j k l
1 RAYALPADU 6 0 3 0 9 121 96 84 13 19
2 YARAMVARIPALLI 6 0 1 0 7 56 49 30 6 8
JINKALAVARIPALLI 8 0 0 0 8 21 32 0 2 4
List Session Sites on the same route for the day in increasing distance from ILR Point
List Session Sites on the same route for the day in increasing distance from ILR Point
#Hard to Reach for AVD means: a)Plain area session > 7km from ILR point,b) Hilly /Malnad area: > 3km, c) Tribal Tandas/ Isolated garden houses/Isolated Migratory HRAs - distance not counted d) Areas un
sub-centre/ Un served areas being served by another ANM
RI Form-13
Name of Person /
Driver
PALGUNA K
PALGUNA K
PALGUNA K
PALGUNA K
RI Form-13
Name of Person /
Driver
PALGUNA K
Name of the Disitrict: ____KOLAR__________________ Block: ___SRINIVASPURA___________________ Planning unit: _____PHC RAYALPADU_________________
Consumable Reusable (Required for each session Site- 1 no. of Functional Hub cutter, Vaccine Carrier & 4 no. of Ice
Packs
Paracet
IFA Zinc Red Black Zipper Vial amol ORS Family Tally Sheet / Functional Hub cutter
Thayi Card Vaccine Carrier Ice Packs AEFI Management Kits
tablets tablet / Bag Polythe Opener tablet/s packet welfare Due list of
No. of Session planned
Bag (One per sub centre area)
syrup ne Bags yrup materials Beneficiaries
Sl. Name of Sub-Center / PHC
Currently available
Currently available
Currently available
Currently available
No. HQ Total No. required
subcenter area
subcenter area
subcenter area
per month
per month
per month
per month
per month
per month
per month
per month
per month
per month
per month
Short fall
Short fall
Short fall
Short fall
session
session
PHC RAYALPADU 4 0 6 4 4 4 1 0 0 1 50 15 1 4 1 1 0 1 1 0 4 4 0 1 1 0
1 RAYALPADU 0 720 3 0 0 0 0 6 4 1 50 15 1 2 0 0 0 0 0 0 0 0 0 0 0 0
2 YARAMVARIPALLI 2 720 2 2 2 2 1 6 4 1 50 15 1 2 1 1 0 1 1 0 4 4 0 1 1 0
3 JIKALAVARIPALLI 2 720 3 2 2 2 1 6 4 1 50 15 1 2 1 1 0 1 1 0 4 4 0 1 1 0
Name & Mobile no. of Medical Officer: ___DR ABARARPASHA_____9480643436__________________________ Name & Mobile no. of Pharmacist:___R MANJULADEVI______9480643693_______________________ Name & Mobile no. of Superv
1 JINKALAVARIPALLI FIXED
July
3 BOORAMEKALAPALLI FIXED
October
4 CHIKARAGEPALLI FIXED
January
1 JINKALAVARIPALLI FIXED
August
3 BOORAMEKALAPALLI FIXED
November
4 CHIKARAGEPALLI FIXED
February
1 JINKALAVARIPALLI FIXED
September
3 BOORAMEKALAPALLI FIXED
December
4 CHIKARAGEPALLI FIXED
March
When to act: ILR/Deep Freezer breaks down OR Electricity failure for more than 18 hours
Who will act: Name and number of Cold Chain Handler/s/Pharmacist:____R MANJULADEVI__________________________________
1-Shift vaccines in cold boxes with conditioned icepacks. Place thermometer inside the cold box.
2- Arrange shifting of vaccines to nearby PHC or other vaccine storage facility.
ILR
____________RAYALPADU__________________________PHC Medical fficer :_____DR
ABARARPASHA_________________________________________
1- Shift ice-packs into cold boxes, if extra cold box is available after shifting of vaccines from the ILR.
Deep Frezer
2- Contact ice-factory:____________________________ , Mr __________________________ to freeze ice-packs.
Company direct:
Record details of breakdown in inventory register, UIP monthly PHC performance report, NCCMIS
Signature of Medical Officer Cold Chain Handler
RI Format-17
Bio-Medical Waste Management Plan
Y/N
@ Y/N
@ Y/N
Signature MO/IC :___________________________________ Signature Nodal Officer :______________________________________
Communication plan for PHC/UHC RI Format-18
Other
Hoardings - location
Counselling aids / job aids (flip books etc.,) - Received on: __/__/____ on:__/__/____
available with - contact person name and number Quantity: ____ to:
Whether
Type of Date Field Re- Re-Estimated Where are Whether RI services Name of the
Whether reesimate planned using mobile
Sl. Re-estimated Estimated Beneficiaries they ANM
No.
Name of the site & Location HRA Validation the site
Population Household
approximat
Migrated team / special team ? responsible
(M1-M5) Done exists ely match
s from? If Yes then for area
survey data
(0-1 years) (0-5 years) Y/N details (day,
week )
A B C D E F G H I J K L M O
Y/N/
Marasanap
1 Chinnarangepalli- Brick kiins M3 April N 2 1 0 0 Newly N Vacent
alli
identified
Y/N/
Jathawarthapalli- Foultrey form M Same
2 M5 Jan-17 N 8 2 0 1 Newly N Vacent
Kurapalli-Foultrey Form Vilage
identified
Y/N/
Rayalpadu S/C,Yerramavaripalli Last one
3 S2 N 6800 1134 105 330 Newly N Vacent
S /C Year
identified
Y/N/ Y/N/
4 hakkipikki s2 old Newly 201 36 2 20 Newly Y/N Vacent
identified identified
Y/N/ Y/N/
5 Newly Newly Y/N
identified identified
Y/N/ Y/N/
6 Newly Newly Y/N
identified identified
Y/N/ Y/N/
7 Newly Newly Y/N
identified identified
Migratory HRA: M1-Slum with migration;, M2-Nommads;, M3-Brick Kilns; M4-Constructions; M5-others;
** List Health facility / Private Practitioner / Traditional Practitioner / Others by name & location
__________ Sub
Name of the
Mobilizer
responsible for
area
Kavitha ASHA
Kavitha ASHA
Lakshmidevamma
ASHA
Lalithamma JrHaF
Lalithamma JrHaF
Total
3
10
3
0
1
Planning unit area - Listing & RI planning for migrant / Se
Name of District:___________________ Block/Urban area: _____________________
Month & year of survey conducted: Month & year of last validation conducted:
Whether RI servic
using mobile tea
Settled If team ?
If migrant
Migran Estimated Estimated Surveyed Surveyed HRA,
HRA or t HRA number of number of are Where
#
Name and Address of High Risk
Migrant number of population they
population site then households at the site Pregnatnt under 1 yr migrated
HRA? Write type of women children
S or M from? Y/N
site*
# Settled high risk site includes : Hard to reach areas, Low immunization coverage areas, Area with refusals, Isolated garden houses, Th
populated slums with low sanitation, Vacant sub centre, areas with measles outbreaks or cases of diphtheria/neonatal tetanusin last tw
* Types of Migratory Sites are categorized as 1- Slums with migration, 2- Nomads, 3- Brick kilns, 4- Construction site, 5- Others)
Migratory/ Settled HR site planning form
nt / Settled high risk areas (habitation) RI Format-9
Planning Unit:___________________
ucted:
I services planned
bile team / special
team ? Distance
(kms) to Name of Healh
Location of nearest RI the worker Name of
Mobile Mobile
session site nearest RI responsible for Influencer
If Yes then session HR area
details (day, site
week )
ses, Thickly
last two years
Signature of MO
Planning unit area - Supervision Plan RI Format-11
Name of District:___________________ Block/Urban area: _____________________ Planning Unit:________________ Sub Centre :________________