Planning form: 1

Template for listing areas with migrant population

State: _________________________

Name and Address of Area

Type of area (code):

1. Slums with migration
2. Nomads

District: _________________________

Type of area
( code number)

Number of migrants

3. Brick kilns
4. Construction site

Number of
households

Block/PHC/Urban Area name: _______________________

Number of under Day of SIA activity as

5 children
per microplan

5. Others

House-to-house team/
mobile team number Day and week
as per microplan
of RI session
(SIA team)

Planning form: 2

Manpower planning form for migratory population

Name of District / Block /PHC/Urban Area: __________________________
House to house activity
Name of the Area

Total

Urban /
Rural

Estimated
houses in the
area (from the
last SIA round)

Teams required

Team members
required

Mobile teams
Supervisors
required

Number of sites with

floating population
and sparse
population to be
covered by mobile
team

Mobile Team
members required

Supervisors required

Planning form: 3

House to House planning form for migratory population

Name of District/Block/PHC/Urban area: _______________________
Name of Supervisor: _____________________________________
Team
Name of team members
Number
Description of area to be
covered
Name & Address of first
house owner with landmark
Name & Address of last
house owner with landmark
No. of houses in the area
Meeting point before
afternoon activity
Description of area to be
covered
Name & Address of first
house owner with landmark
Name & Address of last
house owner with landmark
No. of houses in the area
Meeting point before
afternoon activity
Description of area to be
covered
Name & Address of first
house owner with landmark
Name & Address of last
house owner with landmark
No. of houses in the area
Meeting point before
afternoon activity

Round: __________________
Day 1

Day 2

Day 3

Day 4

Day 5

Planning form: 4

Mobile team planning form for migratory population

Name of District/ Block/ PHC/Urban area: ____________________________________
Team members:_________________________________________
Day
Site 1
Timing of visit
Type and address of area
Timing of visit
Type and address of area
Timing of visit
Type and address of area
Timing of visit
Type and address of area
Timing of visit
Type and address of area
Timing of visit
Type and address of area

Name of Supervisor: _______________________________

Site 2

Site 3

Round: __________________
Site 4

Planning form: 5

Vaccine and cold chain planning form for migratory population

Name of District / Block / PHC/Urban Area:________________________

Name of the Area

Urban/ Rural

Estimated
population

Estimated number
of children below 5
years

Round: _____________________
Total OPV doses
required for each
round

Total OPV vials

required for each
round

Vaccine carriers
Required

Available

Total

Name of the Area

Total
Specify type

Addnl. vehicles
required for
supervisors

Transport for mobile teams

No. of supervisors
using own transport

No. of supervisors

Specify type

Transport for supply of vaccine and logistics

Addnl. Vehicles
needed

Name of District / Block /PHC/ Urban Area: __________________________________________

Vehicles available

Vehicles required

Specify type

Addnl. Vehicles
needed

Vehicles available

Logistics

Vehicles required

Armbands/ Identity
cards

Indelible ink marker

pen

Chalk/ Geru

OPV vial openers

Vaccinator tally
sheets

Planning form: 6

Logistics and transport planning form for migratory population

Round: _____________________
Transport for supervision