Annex-1: Microplanning Format for Immunization Weeks

District

Name of Block/PHC/Urban Planning Unit

Name & mobile no of MOIC __Dr. Gangadhar Pradhan___

AEFI Management Centre address & Tel no:____P.P.C, Deogarh______________

Name, Designation & Tel no of supervisor:__Smt. Rina Guha_________________

Session
: Day &
Date

Name of HRA

25/4/13

Govindpur,
Giripur,
Mohinipur

26/4/13

3
4

S
No

Name &
mobile no of
Mobilizer

Designation
of Mobilizer
(ASHA/ AWW/
Other)

Jhadeswar
Mandir

Sudesha
Bhoi

103

Mukhi Sahi
AW Center

113

48

No of
houses
in HRA

Address of
session site

102

Mukhi Sahi
(Hatisal)

27/4/13

Patrapali
Janghi Kudar

29/4/13

Rajamunda
Munda Sahi

Category
of HRA#

JE Introduced
Pentavalent Introduced

Name, Designation & Tel no of vaccinator:___Bilaisni Baral________________________

Name &
mobile no
of AVD
person

Required number of logistics (self calculated in excel sheet)

Estimated
beneficiaries

Vaccine and Diluent vials

0-2
yrs

Pregna
nt
Women

TT

BCG &
diluent

AWW

39

22

02

Rukmini
Behera

AWW

40

22

Patrapali
AW Center

Sanjukta
Dei

AWW

33

Munda Sahi
AW Center

Fulmanikrip
a Toppo

AWW

14

Pentavalent

Syringes
0.1
ml
AD

0.5 ml
AD

5 ml
Reconstit
ution

10

22

68

14

03

10

22

68

14

04

03

09

19

57

12

01

01

02

08

24

10

DPT

HepB

tOPV

Measles
& diluent

03

05

04

03

02

03

05

04

18

02

02

04

08

01

01

01

JE &
diluen
t

#1- Slums with migration; 2- Nomads; 3- Brick kiln; 4- Construction site; 5- Others (fisherman villages, riverine areas with shifting populations etc), 6- non migratory (settled population) & hard to reach areas
* In Pentavalent states, only a booster dose of DPT will be required

Signature of Supervisor

Operational guidelines: Immunization Weeks- 2013

Signature of MOIC

Annex-1: Ready Reckoner for estimating the requirement of vaccines and logistics
BC
G
via
ls
&
Dil
ue
nts

OP
V
vial
s

0.1 ml
AD
syringe

HR
A
Hou
seh
old
s

HR
A
pop
ulat
ion

0-1
yea
r

02
ye
ars

PW

TT
vials

25
0
50
0

15

15

30

10

f=
(e
x1.3
3) /
10

50
10
0

Mea
sles
vials
&
Dilu
ents

With Penta but

without JE

With Penta & JE

DPT
vials

Pent
a
vials

JE
via
ls
&
Dil
ue
nts

0.5 ml
AD
syringe

5 ml
Reconstit
ution
syringe

DPT
vial
s

Pe
nt
a
via
ls

0.5 ml AD
syringe

5 ml
Reconst
itution
syringe

DPT
vial
s

Hep
B
vial
s

0.5 ml
AD
syringe

5 ml
Reconstit
ution
syringe

v
41

W
5

j
3

44

33

u
1

17

87

14

66

82

g=
(cx
1.3
3)/
10

h=
(dx1
.33)
/20

i=(c*1
.11)

j=
[(1.2
5 X c)
X1.3
3]/5
takin
g
agegrou
p9
comp
leted
mont
hs to
2
years

k=
[(dc)x1.
33]/1
0

l=
(cx1.
33)/1
0

m
=
[(1.
25
X
c)
X1.
33]
/5

n=[d
+e+(
1.25*c
)*2]*1
.11;

o=[1.1
1*(g+j
+m)]

p=
[(dc)x1
.33]
/10

q=
(cx
1.3
3)/
10

r=[d+e
+(1.25
*c)]*1.
11

s=[1.
11*(g
+j)]

t=
(dx1
.33)
/10

u=
(cx1
.33)
/10

v=[d+
c+e+(
1.25*c
)]*1.1
1

w=[1.1
1*(g+j)
]

Aver
age
no.
of
pers
ons
per
hou
seh
old
=5

1. No. of
infants =
3% of
total
populatio
n
2.
All
children
are
unimmuni
zed.

1.
Cumul
ative
no. of
pregna
nt
women
eligible
for TT
injectio
n in a
period
of 6
months
2.
Pregna
ncy
wastag
e is
10%

102

608

20

39

22

02

03

03

22

10

05

68

14

103

667

20

40

22

02

03

03

22

10

05

68

14

Assumptions/Calculations

Without Penta & JE

Operational guidelines: Immunization Weeks- 2013

113

550

17

33

18

02

02

03

19

09

04

57

12

48

230

07

14

08

01

01

02

08

02

01

24

10

366

2105 64

126 70

07

09

11

71

31

15

217

50

Operational guidelines: Immunization Weeks- 2013

Annex-2: Immunization Week Tally Sheet

Daily Report form from session site
Name of PHC
Name of Sub-center
Name of village/area
Children
Less than 1 year
Vaccine
Tally marks

Date of activity
Place of session
Name of HRA:
Number of
children
vaccinated

HRA Category#: 1/2/3/4/5/6

More than 1 year
Tally marks
Number of
children
vaccinated

BCG
DPT1
DPT2
DPT3
DPT-B
HepB1
HepB2
HepB3
Penta-1
Penta-2
Penta-3
OPV-0
OPV1
OPV2
OPV3
OPV-B
Measles1
Measles2
JE-1
JE-2
Women

Pregnant women
Tally marks

Number of pregnant
women vaccinated

TT1
TT2
TT
Booster
issued
AD Syringes

consumed

issued

consumed

Names of staff
1. ANM

BCG Vials

Disposable
Syringes
Measles Vials

BCG Diluents
DPT Vials

Measles Diluents
JE Vials

3.AWW
4. Volunteer

HepB vials
Penta Vials
OPV Vials

JE Diluents
TT Vials

Signatures of ANM

2. ASHA

#1- Slums with migration; 2- Nomads; 3- Brick kiln; 4- Construction site; 5- Others (fisherman villages, riverine areas with shifting populations etc),
6- non migratory (settled population) & hard to reach areas

Operational guidelines: Immunization Weeks- 2013

Annex -3:

Operational guidelines: Immunization Weeks- 2013

Annex -4:

Operational guidelines: Immunization Weeks- 2013

Annex -5:

Operational guidelines: Immunization Weeks- 2013