forms and tools for measles sia (2)
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Name of UC MO: Name and Designation
Mobile no. of UC MO: Mobile no. of UC Superv
Vaccine and Logistics distribution center:
EPI Fixed center 1: EPI Fixed center 2:
Skilled person: Name and mobile number Skilled person:
Team Assistant: Name and designation Team Assistant:
Skilled person: Name and mobile number Skilled person: Name and mobile numbeTeam Assistant: Name and designation Team Assistant: Name and designation
Social Mobilizer 1 Name and designation Social Mobilizer 1 Name and designation
Social Mobilizer 2 Name and designation Social Mobilizer 2 Name and designation
Social Mobilizer 1 Name and designation Social Mobilizer 1 Name and designation
Social Mobilizer 2 Name and designation Social Mobilizer 2 Name and designation
Social Mobilizer 1 Name and designation Social Mobilizer 1 Name and designation
Social Mobilizer 2 Name and designation Social Mobilizer 2 Name and designation
Social Mobilizer 1 Name and designation Social Mobilizer 1 Name and designation
Social Mobilizer 2 Name and designation Social Mobilizer 2 Name and designation
Social Mobilizer 1 Name and designation Social Mobilizer 1 Name and designation
Social Mobilizer 2 Name and designation Social Mobilizer 2 Name and designation
Social Mobilizer 1 Name and designation Social Mobilizer 1 Name and designation
Social Mobilizer 2 Name and designation Social Mobilizer 2 Name and designation
School(s) with tentative target
school name (M:target, P:target)
School(s) with tentative target School(s) with tentative target
Day 2Areas with tentative target:
area name (M:target, P:target)
Areas with tentative target:
area name (M:target, P:target)
Day 7
Day 3Areas with tentative target:
area name (M:target, P:target)
Days
Areas with tentative target:area name (M:target, P:target)
Areas with tentative target:area name (M:target, P:target)
Day 1
Outreach Team 1 Outreach Team 2
Areas with tentative target:
area name (M:target, P:target)
Day 4Areas with tentative target:
area name (M:target, P:target)
Areas with tentative target:
area name (M:target, P:target)
Areas with tentative target:
area name (M:target, P:target)
Day 6Areas with tentative target:
area name (M:target, P:target)
Areas with tentative target:
area name (M:target, P:target)
Day 5Areas with tentative target:
area name (M:target, P:target)
Union Council Vaccination Session Microplan
Measles - Polio SIA, Pakistan 2013
School(s) with tentative target
school name (M:target, P:target)
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Date: ___________________
_______________________________________
1 _____________________________________
_______________________________________ 2 _____________________________________
UC: ____________________ Tehsil: __________________________ District: __________________
Site/Location:
Summery daily report
Full Name and signature of the UC MO:
Full Name and signature of the UC Supervisor:
Measles - Polio SIA, Pakistan 2013
Tally Sheet(To be used on Fixed vaccination centers, Outreach vaccination centers and Schools)
Name of Skilled person:
Name of social mobilizers:
Name of team assistant
_________________________________________________________________________
OPV (0 to below 5 years) Measles (06 months to below 10 years)
Total: Total:
Vaccine Place of vaccination Total children vaccinated Vial received Vial used Vial r
OPVHome
Outreach/Fixed site
Measles Outreach/Fixed site
Pentavalent Fixed site
PCV10 Fixed site
BCG Fixed site
TT Fixed site
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Days TeamTentative target
(Polio)
OPV required
(doses)
OPV required
(20 doses vial)
Tentative target
(Measles)
Vaccine
required
(doses)
A B C D E F G
Sum of tentative
Polio targets of allareas and schools by
day from UC
microplanning sheet
Column C x 1.167 Round up Column D/20
Sum of tentative
measles targets of allareas and schools by
day from UC
microplanning sheet
Column F x
1.11
Outreach
Team 1Outreach
Team 2
Outreach
Team 3
Outreach
Team 1Outreach
Team 2
OutreachTeam 3
Outreach
Team 1Outreach
Team 2
Outreach
Team 3
Outreach
Team 1Outreach
Team 2
Outreach
Team 3
OutreachTeam 1
Outreach
Team 2
Outreach
Team 3
Outreach
Team 1Outreach
Team 2
Outreach
Team 3
Outreach
Team 1
OutreachTeam 2
Outreach
Team 3
Outreach
Team 1Outreach
Team 2
Outreach
Team 3
Outreach
Team 1
Day 4
Day 5
Day 6
Day 7
Measles - Polio SIA, Pakistan 2013Union Council Vaccine and Logistics Microplan
Day 1
Day 2
Day 3
Day 8
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Outreach
Team 2
Outreach
Team 3
Outreach
Team 1
Outreach
Team 2
Outreach
Team 3
Tentative total target
in the catchment area
TOTAL
Day 9
Fixed center
Day 10
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Vaccine
required
(10 dose vial)
Diluent
required
(ampoule)
AD Syringe
(0.5 ml)
Reconsitution
Syringe (5 ml)Safety Box
H I J K L
Round up
Column G/10
Equal to
Column H
Equal toColumn H x
10
Equal to
Column H
Roundup((Column J +
Column
K)/100)
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Sl no. Indicator Target Observation
1Proportion of districts with operational fund available
at least 2 weeks before the campaign.
100%
2Proportion of districts with required quantity ofvaccines and injection equipments available at least 1
week before the campaign.
100%
3
Proportion of district campaign preparation committee
headed by DCO held preparatory meeting at least 10
days before the campaign.
100%
4
Proportion of district campaign preparation committee
meeting minutes shared with the provincial steering
committee within 2 days of the meeting.
100%
5
Proportion of district campaign preparation committee
meeting issues clear action plan with timeline and
responsibility for pre-campaign monitoring.
100%
6
Proportion of UC microplan submitted to the district at
least one week before the campaign of which at least
30% plan are reviewed and validated by the district
level staff.
100%
Measles - Polio SIA, Pakistan 2013Monitoring Preparation of the Measles SIA
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Information source
EDO (Health)/DHO
EDO (Health)/DHO
DCO
Provincial Program
Manager EPI
DCO
EDO (Health)/DHO/Dist
EPI Coordinator
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Name of Observer:___________________________ Designation:______________________________
District: ____________ Province: ___________
1
2
3
4
A. SITE ORGANIZATION
1
2
3
B. SESSION CONDUCTION & INJECTION PRACTICE
4
5
6
7
8
9
10
11
12
13
C. INJECTION SAFETY
14
15
16
17
18
D. AEFI MANAGEMENT
19
20
E. COLD CHAIN
21
22
23
24
25
Team has contact number of the AEFI focal person in the UC and district
Vaccines are stored in standard vaccine carrier with four ice packs
Diluents are kept in vaccine carrier
Both OPV and measles vaccines are given at the center
2 drops of OPV is given to each
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Name of the Observer:_______________________ Designation:____________________ Office:_________________
Village/Mahalla:________________________ Union Council/valley:__________________ Tehsil:________________
District:______________________________ Province/Area:__________
Area type: Urban/Rural Hard to Reach/High-risk population: Yes/No Date:_____/______/2013
(circle as appropriate) (circle as appropriate)
H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
Note:
2. If any serious AEFI is found, immediately notify local authority.
3. Officials of the partner agencies and federal and provincial govt deparments will submit copy of this RCA to the WHO Islamabad
office within 3 days marking "attention: MO-EPI". All others would submit it to the respective DHO office.
Total
1.Please write down name and full address of the missed children/women on the back of the page and share those with local authorit
Measles - Polio SIA, Pakistan 2013Rapid Convenience Assessment (RCA)
All supervisors and independent observers should conduct at least one RCA daily in areas where the campaign has already taken pla
Take cluster in an area where vaccination is already completed. Purposively select area which is suspected to be missed. Do not tak
cluster in an area adjacent to an outreach or fixed vaccination center.
Start in a central location, and pick a direction at random. Begin with the first house facing you. Select and record vaccination status
measles of all target-age children in 10 households. If a household has more than one eligible child, collect data from all.
Send unvaccinated children to the nearest outreach or fixed site. If more than 2 children are found unvaccinated, inform the superviso
or local authority and request to plan a mop-up in that area.
If any AEFI is found, direct the guardian to take the child to a health facility.
HHNumber
Specific Address
HH number or Elder's name
Total number of
children aged
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