Routine Monthly Report Template Page 2
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2MONTHLY IDSR: Please indicate all suspected cases of any of the diseases quoted below.
Data Element
Number
Comments
1. Onchocerciasis; 2. STI; 3. Bilharzia; 4. Kala – Azar; 5. Lymphatic Filariasis; 6. Trypanosomiasis; 7. Rabies; 8. Plague; 9.
Leprosy; 10. Brucellosis; 11. Typhoid Fever.
PART 2
: EXPANDED PROGRAM OF IMMUNIZATION and PHARMACEUTICALS
Please note the EPI report refers to children
Children Under 1
Fixed
Outreach
Total
less than one year of age.
Vaccination Report
1.
BCG
2. OPV0
Tetanus Toxoid Vaccination
3. OPV1
Pregnant
Women 15-
4. OPV2
Women
45
5. OPV3
TT1
6. DPT1
TT2
7. DPT2
8. DPT3
TT3+
9. Measles
10. Yellow Fever
VACCINES/PHARMACEUTICALS
Opening
Received
issued/
Balance ( = left)
balance
discarded/ sent
to other centres
BCG
OPV
DPT
Tetanus Toxoid (TT)
Measles
Albendazole 200mg tabs
Amoxicillin 250mg caps/tabs
Artesunate +Amodiaquine (Adult: 6 tabs)
Artesunate +Amodiaquine (Child: 3 tabs)
Artesunate +Amodiaquine (Infant: 3 tabs)
Artesunate +Amodiaquine (Toddler: 3 tabs)
Ciprofloxacin 500mg tabs
Cotrimoxazole 480mg tabs
Ferrous Sulphate Folic Ac 200mg/0.25mg tabs
Metronidazole 200mg tabs
ORS
Paracetamol 500 mg
NOTE: Please write 0 (ZERO) if the health facility provides services but nobody came for this particular service during this
month period; if the health facility does not provide services please leave the space blank.
Date when the report was submitted
Signature
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