ROUTINE IMMUNIZATION MICROPLAN

KARNATAKA

PLANNING UNIT ____PHC

RAYALPADU____________________

TALUKA SRINIVASPUR

DISTRICT _KOLAR_______________________

SIGNATURE OF MO:
 RI MICROPLANNING INDEX / CHECK LIST

District __kolar__________________ Taluk srinivaspur________________________ Planning Unit:___phc raya

Contents

1 Planning Unit Profile

2 District Map showing Taluk and Planning unit

3 Planning Unit Map showing Sub-Centers, Session sites, AVD and Migratory / High Risk areas

4 Planning Unit area - Estimation of Beneficiaries, Vaccine, Logistics & Sessions

5 Planning unit area - JHA (F) wise monthly session plans

6 Planning unit area - Alternate Vaccine Delivery (AVD) Plan

7 Planning unit area - Logistics planning Form

8 Planning unit area - Supervision Plan

9 Planning unit area - Contigency plan for vaccine

10 Planning unit area - Bio-medical waste storage

11 Planning unit area - Communication Plan

12 Planning unit area - Migratory sites field validation

13 Checklist for Preparing / Reviewing Microplans

Unit:___phc rayalpadu_____

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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

Urban __________ Rural _ __10398_________ Total__10398_________ 9 5 7 5

3. No of Villages / Urban wards 15. Estimated number of RI injections per month

33

4. No of Sub Centres: 16. No. of Syringes required per month:

3
5. No of Panchayat Raj Institutions: AD syringe 0.1 ml AD syrin
3
6. No. of Anganwadi Centers: 20 55 33
7. Estimated / surveyed Population:
SC ST Other Total
Urban 16. Total No. of RI sessions planned per month: __________
Rural 2376 3963 10398
No. at PHC HQ No. of session at Outreach
8. Number of Pregnanies (ILR point) (SC, AWC, others)

SC ST Other Total 4 4

Annual Target 34 54 56 144

17. No. Alternate (Hired) Vaccinators: __________________
Monthly Target 3 4 5 12 18. No. of sessions planned per month with Alternate Vaccin
9. Number of < 1 year Population 19. Status of Coldchain equipment (in numbers)

SC ST Other Total Status ILR DF

Annual Target 42 70 73 185 Working 1 0

Monthly Target 4 6 6 16 Under repair 0 1

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

measles JHA (F) 3

outbreaks
or cases of
Slums with Other Vacant
Nomads Brick kilns Constructio migratory Settled diphtheria/
*Type of sites migration subcentre neonatal ASHA 11
M2 M3 n site M4 HRA* (S1)
M1 sites M5 (S2) tetanus in
last two
years (S3) Cold chain staf 0

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
_______________________

AD syringe 0.5 ml 5 ml Reconstitution syringes

3310 27

h: __________________________

Outreach No. at schools for DPT 5 yrs /

No. of session through mobile team
hers) TT 10y & 16y

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

ned In position Vacant

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

Out Reach Session O

Session with Alt Vaccinators / NGO /

Pvt Sectors
A

Religious place

School S

M1 -
MIGRATORY SITES
M5

Settled HRA Sites S1 - S3

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

House to House survey form

Block / Planning unit :______________________ Subcentre: ________________________________Village/HRA sites: __________________________

If Polio HRA, type of Site: M1 / M2 / M3 / M4 / M5 / Settled

(Settled high risk site includes : Hard to reach areas, Low immunization coverage areas, Area with refusals, Isolated garden houses, Thickly
populated slums with low sanitation, Vacant sub centre, areas with measles outbreaks or cases of diphtheria/neonatal tetanusin last two years)

Name of JHA (F): _______________________________________________ Name of ASHA: _______________________________________________

Name of AWW: _______________________________________________ Name of Link worker: _______________________________________________

Name of HW conducting survey_____________________________________________________________________

Team No:________________________ Date:_____________________

Please use one fresh tally sheet for each day

Name and address of first owner with landmarks:

Total
No. of house visited 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C
No. of house visited 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150
Total family members in the household
Encircle, any if preg women/< 2 yrs child present P C P C P C P C P C P C P C P C P C P C P C P C P C P C P C

Name and address of last owner with landmarks:

Number of houses visited

Total population
Total pregnant women
Total < 2 yrs. Children

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

TT for Pregnant women

e

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

DPT (k+q X 1.11) 10

Taluka: ______srinivaspura__________________

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

Vitamin A {(d X 1ml) +

22
d1

(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

0.1 ml ADS (BCG) (f+j X 1.11)

0.5 ml ADS (e+g+i+k+l+m+q+r) X

h1

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

Monthly estimated Name of Mobilizers with contact number

No. of Sessions required

Beneficiaries

Distance (kms) from ILR

Mention Area
Village / Hamlet/ Urban locality / HRA RI Session categorize Vaccine Name of

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

Infants (0-1 yr)

Yes / No M5)
(Enlist each HRA site separately) (S1 - S3) week to reach* AVD (Y / N) contact number
ASHA AWW Others

per month
(Y / N)

injections

point

TOTAL

HRA Site M1 M2 M3 M4 M5 S1 S2 S3 Total

No. of sites / Areas

Total No. of Pregnanat women
Total No. of Infants
* HRA: M1-Slum with migration;, M2-Nommads;, M3-Brick Kilns; M4-Constructions; M5-others; 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
#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 under vacant sub-centre/ Un served areas being served by another ANM
 Planning unit area - School Immunization plan RI Format-12A

Name of the Disitrict: ____kolar_____________ Taluk: _srinivaspura__________________ Planning unit______________________

Total No. of schools Estimated Beneficiaries per year Vaccine vials required
Sl.
No. Name of Sub-Center 5-6 yrs (DPT TT
Govt 5-6 yrs
Govt Private Others Total (DPT Booster2) 10 yrs (TT) 16 yrs (TT) Booster2) [(i+j)X1.11] /
aided (h X 1.11 / 10) 10

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

TOTAL 20 0 4 0 24 198 177 114 21 31

PLANNING UNIT AREA - ALTERNATE VACCINE DELIVERY PLAN (One format per RI day)

District: ___kolar____________________ Taluka: __srinivaspur________________________ Planning unit: ____ phc rayalpadu____________________

List Session Sites on the same route for the day in increasing distance from ILR Point

Area Time when

App. Time of Time of Mode of
Distance categorized Time Vaccine
Sl. Departure Delivery Transport
Route No. Session Sites Name of ANM from ILR as hard to from ILR from ILR Vaccine Carrier will
No. (Vehicle
Point reach* be collected
Point Point Carriers Number)
(Y / N) back
GUNTTIP
ALLI

1 V LALITHAMMA 6 0 10min 8.15 9AM 3PM TWOWEELAR

2 CHIKARAGEPALLI V LALITHAMMA 5 0 10min 8.15 9AM 3PM TWOWEELAR

3 JINKALAVARIPALLI V LALITHAMMA 6 0 10min 8.15 9AM 3PM TWOWEELAR

4 BOORAMEKALAPALLI V LALITHAMMA 7 0 10min 8.15 9AM 3PM TWEWEELAR

PLANNING UNIT AREA - ALTERNATE VACCINE DELIVERY PLAN (One format per RI day)

District: ___kolar____________________ Taluka: __srinivaspur________________________ Planning unit: ____ phc rayalpadu____________________

List Session Sites on the same route for the day in increasing distance from ILR Point

Area Time when

App. Time of Time of Mode of
Distance categorized Time Vaccine
Sl. Departure Delivery Transport
Route No. Session Sites Name of ANM from ILR as hard to from ILR from ILR Vaccine Carrier will
No. (Vehicle
Point reach* be collected
Point Point Carriers Number)
(Y / N) back
GUNTTIP
ALLI

1 V LALITHAMMA 6 0 10min 8.15 9AM 3PM TWOWEELAR

#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

ted d) Areas under vacant

Planning unit area - Logistics planning Form RI Format-14

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

Total No. required

Total No. required

Total No. required

Total No. required

Total No. required

Total No. required

Total No. required

Total No. required

Total No. required

Total No. required

No. required per

No. required per

No. required per

No. required per

No. required per

No. required per

subcenter area

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

TOTAL 8 2160 14 8 8 8 3 18 12 4 200 60 4 10 3 3 0 3 3 0 12 12 0 3 3 0

 RI Format-15
Planning unit area - Supervision Plan
District: __ KOLAR Block/PHC/Urban Planning Unit PHC RAYALPADU

Name & Mobile no. of Medical Officer: ___DR ABARARPASHA_____9480643436__________________________ Name & Mobile no. of Pharmacist:___R MANJULADEVI______9480643693_______________________ Name & Mobile no. of Superv

Location of RI sessions with timing

Month Week Tuesday Thursday
Monday Wednesday Friday Saturday Sunday
(Out reach day) (RI day)

1 JINKALAVARIPALLI FIXED

April 2 GUNTTIPALLI FIXED

July
3 BOORAMEKALAPALLI FIXED

October
4 CHIKARAGEPALLI FIXED
January

1 JINKALAVARIPALLI FIXED

May 2 GUNTTIPALLI FIXED

August
3 BOORAMEKALAPALLI FIXED

November
4 CHIKARAGEPALLI FIXED
February

1 JINKALAVARIPALLI FIXED

June 2 GUNTTIPALLI FIXED

September
3 BOORAMEKALAPALLI FIXED

December
4 CHIKARAGEPALLI FIXED
March

Signature of Supervisor_______________________ Verified by Medical Officer (Signature):____________________________

 RI Format-16
Contigency plan for vaccine storage

PHC / UHC / Planning Unit:___PHC RAYALPADU__________________________________________7/22/2017

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__________________________________

What to do (Recommended actions)

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.

In case of ILR /DF breakdown, IMMEDIATELY INFORM:

Designation Name Contact No. Email Alternate contact no

Medical Officer : DR ABARARPASHA 9480643436 phcrpd2016@gmail.com

RCHO : CHANDANKUMAR 9448155426

District CC mechanic: Kalyankumar 7760198589

District Cold chain Officer Sureshkumar 9448029870

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

PHC / UHC:____RAYAPADU_____________________________________ 7/22/2017

Meera Envirotech Private Limited

Name and contact number of agency supervisor:_____8105525559________________________

Name and contact number of agency waste collection person:

At PHC/Urban planning unit:

Name and contact number of nodal medical officer :______________________________________________

Name and contact number of coordination personnel:____________________________________________

Name and contact number of ANM coordinator :__________________________________________________

BMW mechanisms at unit
Location

Identified RI session sharps recovery point Y/N

identified Disinfection corner/point Y/N

Sharps pit location Y/N

Y/N

Availability of IEC material on BMW :

Location
@ OPD Y/N EMERGENCY Contact:

`@ Injection Room Y/N 1

``@ Immunization Room Y/N 2

@ OT (Minor / Major / Labour) Y/N 2

@ lab (Liquid waste management) Y/N 3

@ Y/N

@ Y/N
Signature MO/IC :___________________________________ Signature Nodal Officer :______________________________________
Communication plan for PHC/UHC RI Format-18

District:___Kolar______________ Block/Urban area: _______Srinivaspur______________ Planning Unit:___Phc Rayalpadu________________

Activities Quarter - 1 / 2 / 3 / 4

Meetings with Panchayat / BDO / BEO

Local Press agency / journalist- Names and

contact numbers

ARS / MAS / VHSND meetings

Other

IEC materials and display plan dispatched for display

Hoardings - location

Received on: __/__/____ on:__/__/____

Banners - Quantity: ____ to:

Received on: __/__/____ on:__/__/____

Posters - Quantity: ____ to:

Received on: __/__/____ on:__/__/____

Pamphlets / Leaflets Quantity: ____ to:

Counselling aids / job aids (flip books etc.,) - Received on: __/__/____ on:__/__/____
available with - contact person name and number Quantity: ____ to:

Received on: __/__/____

Other Quantity: ____

Name & contact number of PRI Chairman

Name & contact number of BDO

Name & contact number of BEO

Date:____________ Signature of MO:________________________
 RI Forma
Field Validation of Sites with Migratory populations
Name of District:__Kolar___________________ Taluka/Urban area: ___Srinivaspur_____________________ Planning Unit:____Phc Rayalpadu________________ Sub
Centre:_________________
Name of the person conducting Field Validation:____Lalithamma & Asha____________________________
Designation:_______________________________________________

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

Migratory HRA M1 M2 M3 M4 M5 Total

No. of sites / Areas 0 0 1 0 2 3

Estimated Population 0 0 2 0 8 10
Estimated households 0 0 1 0 2 3
Estimated 0-1 yr children 0 0 0 0 0 0
Estimated 0-5 yr children 0 0 0 0 1 1
Please use back side of this form for writing additional information
 RI Format-19

__________ 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 :________________

Planned Visit Day &

SL No Sub-center / Session site Name Supervisor Name Designation Session Site Remarks
Week
 Checklist for RI micro-plan components - PHC / Urban planning unit plan level

District: _______________ Block / Urban area : ____________________ Planning Unit : ____________________

Date of filling the checklist:_______________________

Estimation of Beneficiaries, Vaccine, Logistics & Sessions

1 Map of PHC showing SCs area demarcation Yes c No c

2 Master list of all areas Yes c No c

3 RI microplans from each SC Yes c No c

4 Vaccine delivery plan and route chart Yes c No c

5 Vaccine and logistics estimation per SC Yes c No c

6 Vaccine and logistics for entire PHC Yes c No c

7 MO Supervision plan Yes c No c

8 Cold chain contingency plan Yes c No c

9 Bio Medical Waste management plan Yes c No c

10 IEC and social mobilization plan Yes c No c

11 Training plan (if applicable) Yes c No c

12 Latest coverage chart Yes c No c