REP Form 1 HC Work Plan (Q1,Q2)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: __________________________

Barangay NamePurok NameResult of previous card checks (HR/LR/ND*)QUARTER 1QUARTER 2Date for master listingDates for catch upDate for next door to door card checkResults of latest card check (HR,LR, ND)Date for master listingDates for catch upDate for next door to door card checkResults of latest card check (HR,LR, ND)JanFebMarAprMayJun

REP Form 1 HC Work Plan (Q3,Q4)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: __________________________

Barangay NamePurok NameResult of previous card checks (HR/LR/ND*)QUARTER 3QUARTER 4Date for master listingDates for catch upDate for next door to door card checkResults of latest card check (HR,LR, ND)Date for master listingDates for catch upDate for next door to door card checkResults of latest card check (HR,LR, ND)JulAugSepOctNovDec

REP Form2 Masterlist of childrnForm 2: MASTERLIST OF CHILDREN (0-23 MONTHS OLD)

Name of RHU/BHS: ____________________________________________Name of Midwife: _____________________________Name of Barangay: _____________________________________________Name of BHW: ________________________________Name of Purok: ________________________________________________Date of Completion: ____________________________

Name of ChildAgeBirthdayName of MotherDetailed address in Purok including landmarksPlace if vaccine has been givenPlace if mother recall TT doses RemarksBCGHepB BDPenta 1 Penta 2Penta 3OPV 1OPV 2OPV 3AMVMMRTT1TT2TT3TT4TT5

REP Form 4 Quarterly card checkForm 4: QUARTERLY CARD CHECK IN HIGH RISK PUROK TO MEASURE RISK STATUS IN ONE PUROK Method: DOOR TO DOOR VISITS FOR CHILDREN AGED 12 TO 23 MONTHS

BHS Name: ____________________ Barangay Name: _________________________ Date: __________

Purok Name: _______________________ Health Worker Name: _______________________

Door No.Immunity Gap Card Check (12 to 23 months)No. of Children with No Card (Write name of child with zero dose and no card on the back of this form and check in TCL)No. of Children aged between 12-23 monthsNo. of children with cardNo. of Completely ImmunizedNo. of Partially ImmunizedNo. with zero dose (3 doses of Penta plus MCV1 and MCV2)(Any one dose of Penta or MCV missed) (Card shows no doses received)1234567891011121314151617181920

Form 5 Consolidated monitoringFORM 5: CONSOLIDATED MONITORING OF QUARTERLY CARD CHECKING IN HIGH RISK PUROKS

Health Center Name: _________________________ Barangay Name: ______________________________ Date: ______________

Name of High Risk PurokDate of Card CheckResults of Card ChecksResult of Catch UPNo. of Children CheckedNo. of Children with CardNo. of Completely ImmunizedNo. of Partially ImmunizedNo. with zero dose no. with No Card% Completely Immunized Decision on High or Low Risk % Children without CardsDecision on High or Low RiskDate Catch Up Done for High Risk PurokNo. Penta Dose GivenNo. MCV Given

% of Completely Immunized - In puroks where most children have cards:Number of children with complete immunization X 100Total number of children with cardsHigh Risk Purok: