KARNATAKA TASK FORCE FOR HEALTH HMIS (HEALTH MANAGEMENT INFORMATION SYSTEM)
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- Title
- KARNATAKA TASK FORCE FOR HEALTH HMIS (HEALTH MANAGEMENT INFORMATION SYSTEM)
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-
’ MONTHLY REPORT OF ILC/HLH aCTI/ITILq -
■
f»r trie rionth of
.
Nainr of civ District jlauGnjiH-j UaE*-N
Name of tar Tg. :L^nG-i->Oi<L
NOR TH/
Tl-i/r.N _iAL
No .
SI .
rt-C-TL VI'TILS
L\O o
Part-i,
Name of the PHC;
No.of
Existing:
Target for Ac hi eve me nt Cumulative
the year
during the for the
year
r.,®nth
i>ioi-iLl4 *.-*ct± ViriLo
1. Film shows held
a) By :Mo1th & F.' /.Department
b) Persons Attended
c) Ey other Department
d) versons Attended
"l. FILM STRIP 3H0N3
a) No.of Film strip show conducted
b) Persons attended
III. IV//CP oHONo
a) No .of Shows conducted
b) Persons attended
1 ■/.
pjxjN niiDJa PROGR-.i u-. E
a) Organised by Nealtn Department
b) Persons Attended
"
c) Organised by other Deportment
d) Persons Attended
V.
EXHIBITION
£) No.of Major Exhibitions arranged
b) No.of Persons visited
c) No.of Mini Exhibitions
d) No .of Persons visited
i;--'* jj liLDlr. CaMPalGd->
i/l.
a)
campaign Arranged
b) Persons Attended
c) Press advertisement
d) Press Releases
- 2 c-i
■^o ’
r_t_
ruCTIVliIao
Target for
tne yCcir
,
't
acni evc.aent Cumulative
during the
for the
month
year
.
•
■
WORLD. POPULATION EAI ARRANGED
VII.
1, a) PHD level at H33 -Villages
b) No.of persons participated
2. a) Taluk Level
}. )
Jo.of Persons participated
3- a) District Level
b) Ito .of persons participated
4- a) Stat'- Level
L) ito-of persons particiopted
a) National Level
/
b) No.of Persons participated
.
,
VIII. M .a .a . .t'l.cLLILL.n T 1 3 /lOrtl ariOP
1. a) .District Level
b) No.of persons participated
2. a) Taluk Level
b) ito-of persons participated
EC.
INTI.R-N.-i.Tf ONA.L WORMIN ' 3
Z •Loi.RVID
1. a) District Level
b) No.of persons participated
2. a) Taluk aevel
b) No-of persons participated
3, a) Prto Level ct rioL village
L) i-.o-of persons gurcicipo.t>d
.y •.
' ,
.'
‘xO*
X.
_
-<CTI VlTII.S
It root for
vAr
’
Achievement cumulative
during the
for the
ilonth
yc^r
TWINING & OT.ILR PROGIWu. 1.3
1- a) Mahila zichar vinirr.aya
b) do.of mothers' with one child
participated
No.of 1433 member's participated
No.of others participated specify
II.
a) H_-xj'Tr{y LCY tiriOd
No.of babies participated
Between 6-1.2 months
between 12-24 months
CHILDREN’S Eh.Y «.Rx>.N.OLD
No.of Children's participated
A.TTE SOSEYRNDIRA b<MAVL3H:^
No .o f . pers®ns participated
FOLK MED!-'-.PROGRol-ML oXR.-.NGZO
Ko-of persons participated
GR-.Ma. PaNCrKYr.T HLMBLRo
TRAINING PROGRAi-lriE
Ko.of member's participated
FOijD a.RTI3T‘S WORK oiiOP «-rt<ANGLD
No .of artists participated
«'
4
Education Media
Materials
SI.
No.
— - — — — —
—
Got Locally
produced
— — —
1.
Posters
2.
Folders
3.
booklets
4.
Pamphlets
5.
Slides
i.
Audio cassettes '
7-
video Cassettes
8.
films
9.
Flip Looks
Received , Distributed.^^
from MEM
to Pile's
Wing
■ .
y . •
' '
1
.
/
'
'
34
'
1
■
' ■
'
■
'
10. Others! f any (Specify)
a)
.
b)
■ '■
•
.
.
I’.
■
.. '
c)
d)
•
EJUCATION MATERIALS SUP1-LIED TO MSS
SI No.
of Educational Material
1 .
folders
2.
booklets
3•
Pamphlets
4•
Ibsters
5.
Slides (cinema)
6.
casettes (audio)
,7.
Films
No.supplied
' *•
I .■
,
Remarks
cumulative
i
‘
?
'
,
•
..
■ r
OTHER .aCTI 71 TIES IN i-lSS
■
'
activities
L’aW- •
1.
No.of Dep»t fielders established by MSS
2.
No.of cultural/Folk Media
programme arranged in MSS
3. No.of Education/Motivitional
Activities arranged by MSS
i-iO II L. Cl
tne
cumulative
Remarks
•
5
Si.
No •
juring the
Month
Activities
Cumulative
Rc-ma rks
Out of
Order
Actie »,ta ke.n fo r
Repairs (if any)
Immunisation
5- Spacing Method
6. Anternantal care
7-
of Iron &
EOlic Acid Tablets
jb.L’s tribution
PCSITION OF A .V AIDS
No’
No • i n
Position
Name of the Equipmen
Slides Projects-
Tape Recorders /. Players
Radio
Sets
. Exhibition panel stands
Display boards
other if any (Specify)
VEHICLE POSITION EXCLUSIVELY FOR ISC ACTIVITIES
SI
No
No .of
Vehicles
Type of Vehicle
Position of
Vehi cl es
Remarks
oTHFF POSITION
SI .
.
"
Category of Staff
1- Block Health Educators
------•
Sanctioned
Working vacant Remarks
- 6 ■ '
.'PHYSICAL aND FINANCIAL ACHIEVEMENT FOR THE YEAR 2 ®O®-2 <"'O1 UNDER THE
ISC ACTIVITIES
-,3l.-----------------------
No.
"
“
activities
monthly
target
_
_
_
_
" “c^muiative “ ~patang/
achievement___ forthe/ye*r__
Physi- Finan- Physi- Finan Physi- Finan- Phy Finan_cal_ cial_ _ _cal_ cial _cal |
cial/ steal cial
1, WORLD POPULATION DAY
a) National level. .
. '
'
b) State level
c) District Level
d) Taluk level
e) PHC level
2.
INTERNATIONAL WOMEN’S DAY
a) Taluk level
b) PHC level
3.
M.S.S.PRESIDENT’S WORK SHOP
a) Taluk level
b) District level
4.. "FOLK >*RTISTS WORK SHOP
a.) aistrict level
5.
PHC ACTIVITIES
a) Mahila vichar Vininiaya
b) Healthy Baby Show
c) Children's Day
d) villages level Training
to the MSS Members
6.
ATTE SOSEYANDIRA SaMaVESH
a) Folk Media
b) Grama Panehayat members
training programme
•7.
MISCIUuLANILNCE EXPENDITURE
a) Repair of a. v.Equipments/
Photo publicity
b) Advertisement
c ) Hi ri ng o f Vehi cl es/Auto/Etc .,
g
R , C . P I RM S’
1) MICRONOVA THARMACEAUTICALS ’
51825. - 00
2) LEGEND DRUGS
611600 - 00
HIAIMACEAUTICALS
5) N.S'.A.R. FHAIMACEAUTICALS-
273900 - 00
4) DOMINION phah-iaceauticais;
175000 - 00
5)aUtco phapma
35000 - 00
6) pramat surgical cotton co. ,
1
' 101250 - 00
1
7) CORE HEALTH CARE Co., LTD.,
53865 - 00
LABORATORY
79700 - 00
9) S.M. PHAH-1ACEAUTICALS'
I
5400 - 00
10) S.P.D. R.C. PUM
122500 - 00
11) K.A.P.L. BANGALORE
1034150 - 00
12) MOUNT METTUR & THARMACEAUTICALS
32500 - 00
TOTAL:-
II.
PUBLIC S’ETOR
2576690 - 00
C 0 M P A H I.
1)) BENGAL CHEMICAL CO.,
626300 - 00
2) MAHARASTRA ANTIBIOTICS CO.,
282500 - 00
3) GOA ANTIBITIC CO.i,
130000 -,00
4) ORISSA ANTIBIOTIC CO. ,
■ *
5) 1-D.P.L.Co.,
....................
253937 - 00
204650 - 00
TOTAL J- 1497387 - 00
Ill . PRIMARY MANUFACTURING UNIT:
1) CADHENS LTD. ,
202500 - 00
2) T.A.S.R. Fhaunaceauticals
119000 - 00
5) LIGgWJ) DRUGS & PHARMACEAUTICALS
507000 - 00
TOTAL:
628500 - 00
IV. D.S.M.S
1)
D.S.M.S.
201250 - 00
TOTAL :
1) R . 0 . FIRMS
t
2576690 - 00
2) PUBLIC SECTOR CO.,
-
1497387 - 00
5) PRIMARY MFC. UNIT
-
628500 - 00
4) D.S.M.S.
-
201250 - 00
TOTAL:
4905827 - 00
quarterly
report
on
isc/mass education and
media
activities
Name- of the State: KARNATAKA
- Report' for the Quarter ••
'
Sndingf
-
SI. ..
No.
• No . of Districts
’ No.of Districts Reporting: •
.
; .
activities
Act'ivity-.n particulars
......
------------------------ i;
__
during the During the
.Quarter
Year
■ - -1-)MAHILA S'?USTH?A_SaNGHA_£MSS)
No.of Districts in which t ‘
I.
MSS are functioning;
'-------------- ■---------------------------------------2.No.of Old MSS in Bzist:Once --------•.------------------ - --------- —------- -------3 .No_.pf MSS-Discontinured.
A-;No; of-MSS Constituted
5.Total number of ' members
involved(Old & New MSS)
S.ITo.of MSS Members(01d & New)
■ meeting held
' 7 .Educational materials
supplied to MSS
. ....
\
Posters
-- Eolders
. ..
Booklets
Pamphlets
’ .
- . ’ '
Slides/C.ussettes/Video spots
Film, etc’. .
■ 8.No.of Dep of Holders establi• shed..by.. MSS
‘ : ■
9iNo.of Cultural/Polk Media
programmes’ organised in MSS
10)
No.of
Educational/Motivational
activities organised by MSS
i) Immunisation
ii)Spacing Methods
iii)Ante-Natal Care
•_________ •_
Distribution
iv)
of Iron
and Folic Acid Tablets
-2-
- 2 QUARTERLY REPORT Of IEC/MS3 EDUCATION & MEDIA ACTIVITIES
^Activity Particulars
°’
~
'
During the During the
Quarter
year
’
—II ^TRAINING" OF I*MILA_SWaSTHYa_ SANGHA:
1)No.of Training Programme held
.
2)No.of-MSS Members Trained
3)
No.of
MSS Members yet to be trained
IIl)Twd days jointt
training course:
1.)No-»of-two’days''joint’a" training
programme?held for FEW s/ANMs/AWWs/
— ’ICDS'Supervisors etc.
>
No.of
2)
persons..trained
5)
No.of
persons to be trained
' Iff)Training of BHBs
1)No.of One month BHB's(HFWTC) Training
-- "Programme.held
2,No.of BHBs Trained
■ ■ - J;No".of'BHB' s to be Trained. ’
.
"
- .
’
----------------------------------------
V)MedjAl Activities:
No.of
1)
Film shows held
No.of
2)
Cultural shows
'
'
•3)No.of Exhibition held
4(a)No..ef Hoardings repainted and put up
(b)
No.of,
News-Hoardings put up ”
5(a)No.of Bus hoardings :pain±6<fiag
and putmp
Nb.of
(b)
Bus hoardings put up
.
• .
.
---------------- - ----------------------
6,a)No.of Vehicle- rpaimtfld'c./restencelled
a)No,of
7.
Walls Repainted ;/ . .'
rsstencilled'. ....
b)No. of walls llewly paintsd/
Stencilled
--------- ------------------------------
8»a)No;of Tin plates repainted and
put up-- •
b)No.of new tin plates put up
_____________
/V
-4QUARTBRLV REPORT OF IEC/MAS3 EDUCATION & MEDIA ACTIVITIES
_________ • -a ,
- ---------- ACTIVITIES
Activity'Particulars
----------- ------------------------1,0'
During the During the
____
___________
Quarter . ■ Year_
1S.(a)To tai No.of OCTs Held
.
■(b)No(bf CTCs Held .exclusively for
...
> ;. «
Womeib
'
'—;------'—i------- ~r_--------- —
. (p)No.of persons attending caaps
19.( ajRop'ulation.Edu cation activities
■•-held
(b)No.of activitied held exclusively
for wcoen
-------------- - --------------------20, No.of Adult education classes held
VI.
Hiring
of--TV.& VCRs
1.No.of districts selected
(Attach list.of Districts selected)
2.No.of Video shows organised
VII.Opinion Leaders Caws
1 .No.of Districts selected
(Attache list of 'Districts which
’ canps organised)
2;No.of persons attended ccnnps
3.No.of Educational activities held
VIII,
Local'
Specific'Intencive activities
.. in selected.
districts
I'.No.-of Districts ' selected
(Attached list of districts selected)
2.No.of Activities'organised
(Folk Dances/Street Rlays/Rihu/
t
Tj
/5/
-3' QUARTERLY REPORT ON IZC/I.IEBS EDUCATION & MEDIA ACTIVITIES
t?1* Activities
No. •
Achievement
;
-----------------------------------------During Hie
During the
quarter
; . year
9.
a)No.of
Poster designed
'b)No.of
Folders
designed
Booklets
Pamphlets
10.No.of copies of posters print-ad'-11.No.of copies -Folders
printed.
.Booklets
■’ Pamphlets
12.No.of Press Advertisements released
15.No.of copies printed at the State
Offset press
- -i.No.of copies of posters printed
No-.of
ii.
copies of Folders
printed
Booklets
Pamphlets
’•
• •
—-- — - — __ —
U> — — —•
...
•
' '
—— — —
....
. ..
14.Production of Video Spots/Video Films
1-6 mm-films/?50 mm films
i.No.of Video spots/prints
ii.No.of video films/prints
iii.No.of_16.mm films prints
iv.Mo.of 35 mm films/prints
15.Production of educational Aids
i.No.of slide sets /Prints
ii.No.of Addbo CAsaottnn ta
r
No.of
iii.
flash cards sots
_iv.No.of flip book
v.Programmc- Information kits
“——————————————
vi)Modelo on Vasectomy ,'fubectomy & IUD
16,a)No.of State Level Seminar organised
b)ilo.of Dint.Level Seminar organised
No.of
c)
other seminar organised
17.a)No.o± State Level Workshop organised
b)No.of Dint.Level Workshop organised
(
- 5 ANNUAL BBPORT ON IBC/liASS EDUCATION AND MEDIA ACTIVITIES
audio VISIAL Vans Z1ND EGOZPMBNTS
Si.
No.
Position at the end of
year
Total Nos. Out of order
Aydio Visual Vans and
Equipments
"
1) AV.'Vans
-------------------------- —-----------
2) 1o □□ Filo Projectors .
3) Generators
4) Super 8 no Projectors
Q
' 5) Slide projectors
6) Tape recorders/? layer
7) F? _Ai = 3- _l-:y -v.
8) Photo.Cameras
9) Video Caneras
10) VCSs/VCls ■
11) T .V . Sets
12) Over Head Projsctors
13) Exhibition Pdael Stands
U) Display Board with Population.Clocx
£)i'""j-vi’cA
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- 7 -
.6NNUAL REPORT OF DSC/ L'USS KDUCUTIOi? AND MEDIA ACTIVITIES
OFFSET
STARR POSITION OFOFFSET PRESS
SI.No.
None of the Post
1) Computer
2) Process Op erator
3)' Asst, process Operator
4) Artist
5) Offset Printers
6) Asst.Offset Printers
7) Senior Compositor
8) Compositor
' ?) Junior Conpositor
10) Plate Maker
11) Junior Proff Examiner
1 2) Machine Minder
13) Senior Binder
14) Binder
15) Asst, Binder
16) Asst. Plate Drainer
17) Works Clerk
18) Senior Oifset-Printers
19) Senior Proof Examiner
20) Plate Examiner
21) Sup ervisor
.22) Asst. Director
'
23) S.D.Cs ■
24) Attenders
25) Sup erint endent
Total No.
sanctioned
1
1
1
1.
2
33
1
1
1
1 2
1
.i
11
3
8
1
1.
1
1
1
1
2
2
1
Total No.
in Position
^(^eu-zZt
^Y GYvx
)1L C. l<9 ,\/C~ff')
P1^ E P1
(9 IaTyLCUY
r)
S k'-Lz
Jx/J $ ,
.
I.E.C. Monthly Expenditure Report
Name of the State/UT:
Report For The Month Of:
Sr
No
Activity Particulars
Allocation
by G.O.I
Relen.se
by State
Expenditure
During
the
month
INNOVATIVE
PUBLICITY
1
—
2
During
the
Year
a) New MSS
b)Old MSS_____________ —
—— —
c)Pre-natal Diagonostic
Technique Act
Seminar/Workshops
djlntensive Local Specific
IEC activities in Selected
Distts
e) Training of MSS's etc
f) Training Material for
MSS’s
MASS MEDIA
ACTIVITY
a)Purchase of Hardware
( AV equipments)
b)Expenditure on Software
( AV equipments)
c)Repair of A. V.equipments
d)Other ExpenditurefPIease
specify) x
Total
X Film production,Seminars,OTC camps,S&D,Press Adv.Etc
PM
)
( ivieF-k
cyh
l
(j3 l/Ov-Ppu
k1)k c
J^) p] Ax■</ $ f
,
pi
Skdjl
I.E.C. Monthly Expenditure Report
Name of the State/TJT:
Report For The Month Of:
Sr
No
Activity Particulars
Allocation
byG.O.I
Release
by State
Expenditure
During
tlie
month
During
the
Year
INNOVATIVE
PUBLICITY
1
a) New MSS
—
b)Old MSS
c)Pre-natal Diagonostic
Technique Act
Seminar/Workshops
djlntensive Local Specific
IEC activities in Selected
Distts
e) Training of MSS’s etc
— -------------
f) Training Material for
MSS’s
2
MASS MEDIA
ACTIVITY
a)Purchase of Hardware
( AV equipments)
b)Expenditure on Software
(AV equipments)
c)Repair of A. V. equipments
d)Other ExpenditurefPlease
specify) x
Total
X Film production,Seminars,OTC camps,S&D,Press Adv.Etc
Fk>
A7.AHDA
r0:1. DT’.TRTCT
.'H n<G Entl.G P.bTVT!ED
HE l-TIL1 MG
1
Hospital Pharmacy and Sub-Store
DD Pharmacy.
2
nlood nank
AIDS DD(DQth)
3
MMR
Planning
4
Purchase of
5
Hospital Waste Management
KHSDP
6
IPP ix, ARM Training Centre
PD IPP IX K
7
Drugs maintenance and stores
JU (GMS )
8
Management of STI & RTI
RCH
9
PPC & UFWC
RCH
10
AIDS Managements
PD Aids.
11
Training
12
Administrative matters-Unauthorised
absence, Disciplinary actions.
CAO
13
Vehicle Paintings
DD Trans [Port.
14
staff
CAO
15
Specialists Hospital wise
CAO
16
Audit - AG & Others
CAO-cum-FA
17
NHRC
18
Post Martum, Medicolegal aspects.
Issue of certificate, issue of Rape
victim
JD (M)
19
CMD Hospital P.eferal, Surveillance o :
Communicable diseases in hospital.
TO
(CMD).
20
Clinical fees and Hospital Teaching
to Institutions.
i TO
(M)
Equ Lanentn A i :a'.nten.ince
SIHFW
•
HEO
M-cU <X<‘d+tX
HET A. STHFW
Dr.Makapur.
_____
JD(M )
The above Programme officer.-, .pre re<u ier. t nil to
submit the reiJorts to the Joint D.ii<-'--ior (Medina L )
for taking further action on the m-.t-r.
DIP. ECT OP.
OF
HEALTH
tmiivd lately
9 FW SERVICES
A
PHC:
A
Monthly Report of NMEP for the Month
PHC :
MF '1 O' Monthly Reports of passive, DDC'S Including treatment depots for the month of
OPD New Cases
SI.
No.
Name of the Passive
DDC'S FTD'S
No. of fever
No. of
cases
Opened
fever cases
New & Working
treated with
treated
Treated
Old
4 A.Q.
New
cases
Balance of Drug's
Blood
smears
collected
No. of
positives
4 A.Q.
Consumed
No. of RT
Given
No. of 8
A.Q.
consumed
4 A.Q.
8 A.Q.
Remarks
R.T. Given
Positives
Fever Cases
B.S. Drawn
Function
ESST
R.T. Given
Positives
B.S. Examined
B.S. Drawn
Fever Cases
Functions
B.S. Examed
DDC'S
FTD'S
ESST
Ia:
—
Given
Positives
ESST
BIS Examid
Establi
shment
BIS Drawn
Name of the PHC
Fever Cases
SI.
No.
Function
Malaria Clinil
PHC :
MF 'S' Monthly Report of NMEP for the Month
Achivement
Spray
Targerj
SI.
No.
Name of Section
Popula
Insecticide
tion
Rounds
period
spray
Balance of insecticide in KG's
at the end of spraying
Years
Covered
Years
cs
Rooms
Rooms
CS
Rooms
CS
Jan.
Feb.
Mar.
Apr.
May
June
July
DDT
50%
DDT
75%
BHC
Malathin
Re
marks
PHC :
MF 'S' Monthly Malaria Programme for the month
SI.
No.
Name of Section
Male
Fe
male
Total
PV
R
RG
Mass theraphy measures
Total focal Total fever
Single dose 4
cases
spray rooms
Single dose 4
AQ & 8 AQ
including treated l.C.
Total
AQ + Prima
4 A.Q.Tabs 600 MG + 450
C.S.
Quine
MG
R.T. Given
Species
Positives
Mix
Total
PV
PF
RT5
Days
Deaths
due to
P.F.
Balance
Tabs
4 AQ 8 AQ
Section
No's
Name of the Sections
TOTAL
Population
Collected
Collected
Passive
B.S.
Examined
Positives
Collected
CD
B.S.
Positives
;s & contact
Eamined
Collected
TOTAL
Examined
Positives
0-1 years
1-4 years
5-14 years
Age-wise
<
.
15 years &
above
0-1 years
15 years &
above
Deaths due to
PF
Remarks
Positives
5-14 years
PF & MIX
1-4 years
MF 4 for the month of
smears
Positives
:tive Blood
Examined
P.H.C.
No.1 Stock position of anti malarial drugs and insecticides
Month
SI.No.
Particulars
1.
4 AQ Tab's
2.
8 AQ Tab's
3.
DDT 50%
4.
DDT 75%
5.
BHC
6.
Malathine
O/B
Receipt
Total
Expd.
Closing Balance
Encuirnmental measures impliments for the malaria control under new strategy in
Bangalore (U) District
M onth
Name of
the PHC
Name of the
illors
(Probe mate)
Type of
mosques
breeding
plates
No. of
freeding
places
introduced
with larve
verous fish
Type of fish
introduced
Other type of
Collaborating
control
agency
activity taken
Remarks
N.L.E.P. REPORT (II)
National Leprosy Eradication Programme
(To be submitted to JOINT DIRECTOR (LEPROSY)
Monthly Progress Report for Endemic / Non endemic Districts
PHC/SECTOR :..................................................
Reporting Month
•
1
1
'
1.
TOTAL
MB
SSL1 PB
.........1...
Total New cases detected during the month
Out of the new cases detected above how many one of
i)
Grade 11 disability
ii) Child Cases
iii) Single lesion casea
9 No. of cases newly inducted on MDT during the reporting
Month out of new cases
3.
No. of relapsed/PLR/Restarted treatment during reporting month
4.
No. of cases discharged during reporting month on account
of following
•
a) RFT after MDT among cases under item 4
b) Due to Death among cases under item 4
c) Other discharges among cases under item 4
No. of cases out of balance on register under MDT at the
W end of Month
Adult
6.
PB
Drugs received during the month
(
Durgs consumed during the month
7.
Adult MB Child
Child
Have you submitted audited report of previous year
YES/NO
If yes, when & to Whom ?
(
If no give reason
A
J.
Funds Received during the month
i.
Spent during the month
10. Any other comments
N.L.E.P. REPORT (III)
information
Additional
( To be Enclosed along with Monthly Report) .
MONTH:
YEAR:
DISTRICT:
URBAN
RURAL NO. OF
Persons
Villages
covered
Persons
TownsAVards
covered
MB
TOTAL
I
1. x No. of Persons Enumerated
2.
No. of Persons Examined
PB
3.
4.
5.
6.
NO. OF
No. of cases detected during the month. By
a.
Population Survey
b.
Contact Survey
c.
Voluntary Reporting
d.
Special Group Survey •
e.
Any other method
Mode of detection for MB only
a.
Patches only (six and above)
b.
Nerve involvement only
c.
Clinical signs
No. of cases treated with
i)
With MDT
ii)
With Monotherapy
Total No. of Villages
With no cases
With PB cases only
With MB cases only
With both MB & PB Cases
■-
With no data
7.
No. of cases detected in following groups
............................................... ......... ...............
Schedule Tribes
.........................................................................
Muslims
.........................................................................
Christians
...........................a..............................................
Others
............................ )............................................
ADULTS
8.
Total Cases on Hand
9.
No. of singio lesion
cases verified by
-DLO/MD/OTHS-------9/~b 1^1-0 j/^l 0 j
Male
ON HAND
NEW CASES
Schedule Caste
PB
Female
ADULTS
CHILD
Male
Female
Male
Signature .
NAME
Designation
Female
MB
Male
CHILD
Female
N.L.E.P. REPORT (I)
NATIONAL LEPROSY ERADICATIN’PROGRAMME - INDIA
Monthly Progress Report for Endemic/Non-endemic Districts/State,
District
:
PHC/Sector
:
Date of Starting of MDT
:
At inception of MDT (Pre-MDT)
No. ot active
cases on register
PB
MB
Total
1
2
3
g =■
0.2
2 c
\ g
4
Banglaore Rural District
Reporting Month :
Yea’r :
16th August 95
From inception till end of reporting month (Cumulative)
No. of cases
No. ol cases
i
No. of eases
'detected since
(Pre-MDT+New cases) ;
(Pre-MDT+Ncw cases)
MDT Starting
inducted on MDT ‘
discharged as RFT
____ ° ......
1
_
SSL PB MB TOTAL SSlJ PB : MB ! TOTAL i SSL; PB i MB TOTAL
;
-1 |
567
8
9 !’1O i 11 j
12 . | °3 | 14 ,j 15 ... 16
r : t
F r-F
___
! :M
°
i
1
!
;
!
____ _• 1
•
SSI
1.
No. of registered cases at the end of previous vear
31st March
2.
No. of cases newly detected during current year till
the end of reporting month (from 1st April)
(a)
(b)
(c)
No. of grade II disability cases among item 2
No. of child cases among item 2
No. of single lesion cases among item 2
3.
No. of cases newly detected during reporting month
4.
No. of cases newly inducted on MDT from 1st April
upto end of reporting month
. —
5.
No. of relapased/PLR/restarted treatment from 1st
April to till end of the month -',nDrt
6.
No. of cases discharged during the.current year from
1st April upto end of reporting month
(a)
RFT after MDT among cases under item 6
(b)
Other discharges among cases under item 6
7.
No. of cases balance on the register at the end of
reporting month (1+2+5-6)
/
8.
No. of cases under MDT out of item 7 are under MDT
9.
Have you submitted audited report of previous year
utilisation certificate of previous year
(i)
If yes, when & to whom
(ii)
If no. give reasons
PR
o
MR
TOTAI
_ ..
o
-
Yes or NO
-
Position
DRUGS (BCP)
-
SSL Adults
-
SSL Child
-
PB Adults
-
PB Child
.
....
’.
'
:................................
-
MB Adults
-
MB Child
-
11.
' . ’
;
BALANCE IN STOCK AT THE END OF THE MONTH
/...............................
Position of MDT Funds :
(a) Amount received forwarded
from previous year
-
(b) Amount received during
the year
-
• (c) Amount spent in cun-ent
year
-
(d)
Balance on hand
12.
Any other Comments :
-
Note : Items 9 & 1 1 are meant for Districts only
nn«i Irttxitivw:! borif;!?‘>':\zl.'.ri\i.r^>>'.jnl'n'to ,oJ4
Name
...j. :tr [llrj ||j} oj jhqA
... . ----------Designation
:
-
, postal Address
Printed by : The Director of Priming. Stationery* and Publications. Government Press. Bangalroe. I W.D Po5416 - P3 New.
& 8.^
A copy of this page should also be sent directly to the Director, State TB Training
and Demonstration Centre (STDC) of your State
Laboratory Quality Control Network All Tuberculosis Units Combined (including DTC)
Initial
reading
Number
Supervisor reading
of slides
checked Number of Number of
positives negatives
Percentage of
Discordance
Postive
slides
(a)
(b)
(b/[a+bj)
[false positives]
Negative
slides
(c)
(d)
(c/[c+d])
[false negatives]
Staff Position andTraining
(Tick [/] if in place or not during quarter)
District Tuberculosis Officer in place
Q Yes
Q No
Trained in RNTCP
Q Yes
Q No
Statistical Assistant in place
Q Yes
l~~l No
Trained in RNTCP
Q Yes
Q No
Treatment Organizer in place
Q Yes
No
Trained in RNTCP
Yes
No
Laboratory Technician in place
Yes
No
Trained in RNTCP
Yes
No
Trained in RNTCP
in past quarter
Total trained
in RNTCP
Indicate numbers at all Tuberculosis Units and DTC combined
Category of staff
Sanctioned
Medical Officer of the DTC
Designated Medical Officer
(TB) of theTB Unit
SeniorTreatment Supervisor
(STS)
SeniorTuberculosis Laboratory
Supervisor (STLS)
Laboratory Technician/
Microscopist
Treatment Organizer
Medical Officer
(at BPHC/CHC/PHC/other)
Pharmacist
Lady Health Visitor
Staff Nurse
Health Assistant
Multipurpose Health Supervisor
Multipurpose Health Worker
or equivalent
TB Health Visitor
Anganwadi Worker
Trained Dai
Community Volunteer
Not Applicable
In place
Medications
Item
Stock on first Stock received Patients started Stock on last Quantity
day of quarter during quarter on treatment day of quarter requested
during quarter
Category 1
patient-wise box
Category II
patient-wise box
Category III
patient-wise box
Item
Stock on first Stock received
day of quarter during quarter
Consumption Stock on last
during quarter day of quarter
Quantity
requested
Pouches for
prolongation of the
intensive phase
INH 100 mg
Streptomycin 0.75 g
Rifampicin 150 mg
Pyrazinamide 500 mg
Consumables
Item
Sputum containers
Slides
Carbol fuchsin
Methylene blue
Sulphuric acid
Phenol
Xylene
Immersion oil
Methylated spirit
X-ray film
Stock on first Stock received Consumption Stock on last Amount to
day of quarter during quarter during quarter day of quarter be obtained
MANAGING THE RNTCP IN YOUR AREA
Annexure V
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Monthly Report on Logistics and Microscopy
Peripheral Health Institution Level
Name of Peripheral Health Institution:
_
-------------------------------------------------
Month:Year:
Medications
Item
Stock on first Stock received Patients started Stock on last
day of month during month on treatment day of month
during month
Quantity
requested
Category 1
patient-wise box
Category II
patient-wise box
Category III
patient-wise box
Item
Stock on first Stock received Consumption Stock on last Quantity
day of month during month during month day of month requested
Blister packs for
prolongation of the
intensive phase
INH 100 mg
Streptomycin 0.75 g
Rifampicin 150 mg
Pyrazinamide 500 mg
Staff Position and Training
Category of staff
Sanctioned
Medical Officer
Laboratory Technician
Pharmacist
Multipurpose Health Worker
-
Other
62
In place
Trained in RNTCP
IMPLEMENTING THE REVISED RECORDING AND REPORTING SYSTEM
The section below is to be completed by Microscopy Centres only
Consumables
Item
Stock on first Stock received Consumption Stock on last Quantity
day of quarter during quarter during quarter day of quarter requested
Sputum containers
Slides
Carbol fuchsin
Methylene blue
Sulphuric acid
Phenol
Xylene
Immersion oil
Methylated spirit
(if supplied)
Microscopy and Treatment Initiation
(a)
Number of chest symptomatic patients whose
sputum was examined for case-finding (diagnosis)
(b)
Number of smear-positive patients diagnosed
(c)
Of smear-positive patients diagnosed (b). number
put on treatment
Equipment
Item
Number
In working condition
Not in v/orking condition
Monocular microscopes
Binocular microscopes
Name of officer reporting (in Capital Letters):
___ _______
Signature:
Date-_________________
63
5
Equipment in place
Item
Number
Monocular microscopes
Binocular microscopes
X-ray machine
Photocopier
Computer
Air conditioner for drug
storage area
Overhead projector
Jeep
Two-/three-wheeler
Name of officer reporting (in Capital Letters):
Signature:
Date:
In working condition
Not in working condition
Mi
dtp/9
PERIODIC DTP REPORTS
(To be submitted by DTC monthly/quarterly to higher authorities)
State:
Period:
(Month/Quarter)
District:
g
SECTION A: Report on Implementation
Total
1. Health institutions that can be implemented as
2. No. of PHls implemented under:
(a) Short Course Chemotherapy (SCC)
(b) Standard Regimen (SR) only
(c) Total implemented (a+b)
3. Total No. of PHI Monthly Reports included
SECTION B: Report on case-finding
NewTB patients detected
Examinations
X-ray
New outpatient
attendance
1
2
Sputum
Total
Nev/
Total
New
Sputum
+ ve
(B)
3
4
5
6
7
DTC
PHI
Total
38
Sputum -ve
but X-ray
+ ve
(X)
Extra
pulmonary
(E)
Total
8
9
10
SECTION C: Report on Treatment
(i) Standard Regimen (excluding patients put on SCC)
Patients put on treatment
1
New
Re-treatment
Transferred from
other centres
2
3
4
Patients
changed from
SCC to SR
Completed
treatment
period
Patients on treatment
at the end of the period
5
6
7
DTC
PHI
Total
(ii) Short Course Chemotherapy (SCC)
Patients pul on treatment
1
' DTC
PHI
Total
New
Re-treatment
Ra
Rb
Transferred from
other
centres/facilities
2
3
4
Completed
treatment period
(RA)
Patients on
treatment at the
end of (he period
5
6
DTP/9
SECTION-D: Details for each PHI (List all PHIs implemented under SCC/SR categorywise)
1
New TB patients
detected
New
outpatients
Total
New
Total
2
3
4
5
6
On TTT at the end
of the period
Number of supervision
visits by
Sputum
+ ves
Sputum
+ ves
put on
SCC
SCC
Standard
regimen
DTO
TO
LT
7
8
9
10
11
12
13
Total
Signature of SA:..........................................
Date:............................................................
Note: i) Separate sheets may be used for SCC & SR.
Signature of DTO:.......................................
Name:.........................................................
Date:.............................................................
ii) List out XCs first, followed by MCs & RCs.
DTP/9 (continuation)
Name of the PHI
Sputum
examination
No. of
monthly
reports
included
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Quarterly Report of Sputum Conversion of
New Cases, Relapses and Failures
Patients registered during
Name of area:
quarter of 19
_____________________
No
Name of Reporter:Signature:
Date of completion of this form:
Complete this proforma for sputum smear-positive patients. The total number should be the same as in
the Quarterly Report on New and Retreatment Cases of Tuberculosis of the previous quarter.
Total number
of new
sputum-positive
. patients
Total number
of smear-positive
relapse patients
Sputum at 2 months
Negative
N.A.
Positive
Negative
Positive
N.A.
Sputum at 3 months
Negative
Total number
of smear-positive
failure patients
Sputum at 3 months
Positive
N.A.
Sputum at 3 months
Negative
Positive
N.A.
N.A. - Not available; sputum examination was not done.
2'97
________
tffLF YEARLY REPORTON DTP RESOURCES'
' "
(To ba sent to sj^Pied authorities for half year ending on 30th June & 3'.WBecember)
State:
Period:
DTP:
SECTION A: Staff Position in DTC (as on 30th June/31st December)
Post
Name of
Person
nel
1
2
NTI Training
Whether
train ,ed
(Yes/No)
If yes,
batch
no/year
Remarks
(If vacant
from what
date)
3
4
5
..
SECTION B: Equipment Position (as on 30th June/31st December)
Equipment
Whether
available
(Yes/No)
Whether In
working
condition
(Yes/No)
If 'No’ In col.3, steps
taken for
repair/replacement
1
2
3
4
1. Dist. TB Officer
1. X-ray Unit
2. X-ray Technician
2. Odelca Camera
3. Lab. Technician
3. Microscope
4. Treatment Organiser
4. Vehicle
5. Statistical Assistant
SECTION C: Remarks on supply position of MMR rolls, Chemicals, stains etc.
Signature of DTO:
Date:
d±Q
Name of the DTO:
MONTHLY REPORT
TUBERCULOSIS FOR THE MONTH OF 4k
DTP/3
19
PART I : Information on case-finding activity during the month
Nameof PHI
(i)
Total new out-patients registered
NEW
Category : XC/MC/RC
OLD
(ii) (a). No. of X-rays taken
Whether implemented under SCC Yes/No *
(b)
No. of sputum smears examined :
(c)
No. of sputum smears referred
(iii) PARTICULARS OF NEW TB PATIENTS DIAGNOSED (INCLUDING EXTRA PULMONARY)
Date
No.
Sputum
Smear No/
X-ray taken
1
2
NAME
Father's Name
Age
Sex
3
4
5
6
Complete Residential Address
including head of the family
house number, street/hamlet.
Village & P.O./Town, Taluk &
District
7
8
-
Strike out whichever is not applicable
Note:
1)
Parts I & II are to be filled by PHI's & part II onlyby Treatment Section of DTC.
2)
This report is to be prepared on the last working day of the month and sent to DTC (Statistical Assistant)
by 5th of the next month at the latest.
Result
Case
Sputum/ Index
Number
X-ray
Extra
-pul
.
9
PART II INFORMATION ON TREATMENT ACTIVITIES DURING THE MONTH
Details
"
Sputum Positive Srtients put
on Short Course Chemotherapy
1
TB patients put on Standard
Regimen
.23
1. TB Patients under Treatment (T T T) at the beginning of the month
TTT cards prepared/received during the month
a)
b)
c)
d)
For new TB patients starting treatment
For TB patients put on tetreatment SiSSnic ..
For TB patients transferred from other centres/facilities
For TP patients for whom regimen was changed from SCC to SR
i
■
2. T T T cards despatched to DTC for transfer of treatment including transfer
cards sent along with this report---------------- -------- ,
3. Other TTT cards despatched to DTC with,this report (TB patients lost from
treatment, reported dead completed optimum treatment period, treatment stopped
by MO including for those on prolonged .treatment, change of regimen from
SCC to standard regimen)
■ i
•
J‘
4. TB patients under T T T at the end of the month.
5. No. of TB patients completing intensive phase under SCC (Regimen A)
Special remarks by M.O. of PHI on availability and use of:
TO BE FILLED BY SA AT DTC
Dates of:
a)
Microscope
b)
X-ray equipment
c)
d)
Date
a)
Receipt of MRT........................
b)
Checking MRT.........................
Anti TB drugs
c)
Indexing new TB patients from RMT.............................
Chemical, stains etc
d)
Including this MRT in ......................
Signature of MO........................
i)
Monthly DTP report........................
ii)
Quarterly DTP report...... ...............
Signature of SA.............................
REVISED
NATIONAL TB CONTROL
FROGRAI H IE
NAME OF PIIC/ PHU
MO-TC:
................. REPORT FOR THE MONTH OF.
P0PLUAT10N .....................................................
1
No. of New OPD
2
No. oE syinptoma tics with cough
of ^3 weeks referred for
sputum examination.
3
No. of sputum positive TB
patients.
4
z
No.- of sputum negative
positive TD patients.
5
No. o£ extra-pulmonary
positive TB patients.
6.
Treatment under RNTCP
a)
CAT I
b)
CAT II
C)
CAT III
■
.
:......
—
s x-r.ay
New
I
FU *
■
Treatment not under RNTCP
0
No. of T0 patients referred
from other PHC/ UTC
CAT 1
ISP ‘
POS)
F] NAL
FU *’
a
-
'7
I I ,
FU 1
CA T
I1
(SP .
POS)
CAT
111.
Other
s
9 ’ Treatment outcome
Category
Cured
Tt .
complc ted
Fa i1ur e
d e f a 11 1. .
Led
Trans
T>.i. nd .. ' I’ c r r c
d out
CAT I
—
CAT'fI
CAT III
■------------ — .
• -•
Others
Oa/'e:
■ I’1 0.CC
REVISED^ATIONAL TUBERCULOSIS CONTROL PROGRAMME
Quarterly Report on the Results of Treatment of
Tuberculosis Patients Registered 12-15 Months Earlier
Name of area:________________________No:__________
Patients registered during
Name of Reporter*:_________________________________
Date of completion of this form____ __________ 19_____
_________ quarter of 19_____
Signature:_________________________________________
Type of patient
Patients
reported during
quarter”
Cured
(D
Treatment
completed
(2)
Died
Failure
Defaulted
(3)
(4)
(5)
Transferred to
another district
(6)
Total number
evaluated (sum of
columns 1 to 6)
NEW CASES
Smear-positive
Smear-negative
—
—
Total
RETREATMENT CASES
Smear-positive relapses
Smear-positive failures
Smear-positive Treatment
After Default
Others treated with Category II
Total Category II
• The Reporter is the Medical Officer responsible, not the person completing this form. This form includes patients on Category I, Category II and Category III treatment,
both smear-positive and smear-negative. These totals should match those of the Quarterly Report on New and Retreatment cases for the quarter.
" Of these,(number) were excluded from evaluation of chemotherapy for the following reasons:
12/97
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Quarterly Report on Programme Management and Logistics
District Level
Name of the District:
Quarter:
Number of Tuberculosis Units planned in the District:
Year:
Number of Tuberculosis Units operational in the District:
Total population of the District:
Population of the District covered by the RNTCP:
The following reports are enclosed (Tick [/] to indicate that report is enclosed)
|~l
Quarterly Report on Case-Finding (number of TB Units reporting":)
l~|
Quarterly Report on Sputum Conversion (number of TB Units reporting":)
I"]
Quarterly Report on Treatment Outcomes (number of TB Units reporting":)
" If any TB Unit did not report, list name(s) and report(s):
Supervisory Activities by the Staff of the DTC
Type of Unit
BPHC
Microscopy Centre
Treatment Centre
Patient's Home
Other:__________________
■
CHC
Ji
PHC
ft!
Sanitorium/TB Hospital
I
Government Hospital
Number participating in
the RNTCP
I
l1
TB Unit
Number in the
District
Number of these visited
during quarter
Microscopy Activities (allTuberculosis Units including the DTC)
(a)
Number of new adult outpatient visits in health facilities
(b)
Out of (a), number of chest symptomatic patients whose sputum
was examined for diagnosis
(c)
Out of (b), number of smear-positive patients diagnosed
Treatment Initiation (allTuberculosis Units including the DTC)
(d)
Of the number of smear-positive patients diagnosed (c), the number who
reside within the district
(e)
Of the smear-positive patients diagnosed who reside within the district (d),
number put on DOTS
(f)
Of the number of smear-positive patients diagnosed who reside within
the district (d), number put on treatment other than DOTS
| (g)
"
Initial defaulters among smear-positive patients diagnosed and residing
within the district (g = d - e - f)
Activities of Community Volunteers
Number of Community Volunteers engaged during quarter:
Number of Community Volunteers paid during quarter:
Total amount paid to Community Volunteers during quarter: Rs
MONTHLY REPORWN TUBERCULOSIS FOR THE MONTH OF
.T...... 19
DTP/8
PART I: Information on case-finding activity during the month
Name of the PHI:
(i)
Total new out-patients registered
(ii)
(a) No. of X-rays taken
Category: XC/MC/RC*
New
Old
(b) No. of sputum smears examined
Whether implemented under SCC: Yes/No*
(c) No. of sputum smears referred
(iii) PARTICULARS OF NEW TB PATIENTS DIAGNOSED (INCLUDING EXTRA PULMONARY)
Date
Sputum
Smear No./
X-ray Token
No.
Name
Father's Name
Age
1
2
3
•4
5
Sex
Complete residential address
including head of the family,
house number, street/hamlet,
village & RO./Town, Taluk &
District
Result
Sputum/
X-ray
Extra-Pul
Case
Index
Number
6
7 '
8
9
* Strike out whichever is not applicable
Note:
1. Parts I & II are to be filled in by PHIs & Part II only by Treatment Section of DTC.
2. This report is to be prepared on the last working day of the month and sent to DTC (Statistical Assistant)
PART II: INFORMATION ON TREATMENT ACTIVITIES DURING THE MONTH
1
Details
Sputum positive patients put on
Short Course Chemotherapy
TB patients put on standard
regimen
1
2
3
1. TB patients under treatment (TTT) at the beginning of the month
2. TTT cards prepared/received during the month
a) For new TB patients starting treatment
b) For TB patients put on retreatment
c) For TB patients transferred from other centres/facilities
d) ForTB patients for whom regimen was changed from SCC to SR
X
3. TTT cards despatched to DTC for transfer of treatment including transfer
cards sent along with this report.
4. Other TTT cards despatched to DTC with this report (TB patients lost from
treatment, reported dead, completed optimum treatment period,
treatment stopped by MO including for those on prolonged treatment,
change of regimen from SCC to standard regimen).
5. TB patients under TTT at the end of the month.
X
6. No. of TB patients completing intensive phase under SCC (Regimen A).
Special remarks by M.O. of PHI on availability and use of:
a)
Microscope
b)
X-ray equipment
c)
Anti TB drugs
d)
Chemicals, stains etc.
TO BE FILLED BY SA AT DTC
Dates of:
(a) Receipt of MRT
(b) Checking MRT
(c) Indexing new TB patients from MRT
(d)
Including this MRT in
Date:
Signature of MO
(ii) Quarterly DTP Report
Signature of SA
Part II : DTP/8
(i) Monthly DTP Report
<
$
DTP/10
ANNUAL REPORT ON COHORT ANALYSIS
(To be sent by DTC to higher authorities by 30th April of the following year)
-■?
State’
S
period of diagnosis of cohort*:
g
SECTION A: Report on Treatment (Cohort) Analysis — for Standard Regimen
j
1st January 19
31st December 19
1
No. of TB patients diagnosed during cohort period specified
|-------------]
2.
a) No. of smear positive patients diagnosed
|
~|
b) No. of smear positive patients initiated treatment under standard regimens |— ;------ 1
(
■;
®Year of Report:
DTP:
£
No. of treatment cards of TB patients at SI.No.2(b) available
4.
Out of SI.No.3, No. of treatment cards not considered for anlaysis due to:
[
|
a) Migration ofTB patients (immigration and emigration)
|-------------- 1
b) Duplicate treatment cards found
|
c)
Illegible entries with regard to collection of drugs
|
d)
Total (a to c) r
|
5.
No. of treatment cards considered for cohort analysis (Item 3 minus 4(d))
6.
Distribution of smear positive patients (SI.No.5) according to number of
collections made:
,
—|
|
|
Number of monthly collections made
Details
12
11
10
9
8
7
6
5
4
3
2
1
tto. of smear + ve TB
patients
Cumulative distribution
Cumulative as % of TB
patients undergone
treatment
7-
Final follow up examination of smear positive cohort patients at the end of
treatment period:
a) No. of TB patients for whom smear was examined
b) No. of TB patients for whom smear was found positive
Note:
@ year Of report wj|| be calendar year
* The cohort period will be January to December of the previous calendar year
p.t.o.
No. of ‘O collection’ cases:
41
SECTION B: Report on treatment (cohort) analysis — Patients put on SCC-Regimen A
1
No. of smear positive patients put on SCO Regimen A(2EHRZ/6TH) in the
cohort period (1 st January to 31 st December of previous calendar year)
2.
No. of treatment cards available in respect of TB patients at SI.No.1.
3.
Out of treatment cards at SI.No.2, No. of treatment cards not considered for
analysis due to:
. f
a) Patients migrated (immigrated/emigrated)
b) Duplicate ttt cards found
c) Illegible entries with regard to collection of drugs
d)
Change of regimen from SCC to SR
>
e)
Total (a to d)
I
4.
No. of treatment cards of patients considered
for cohort analysis (SI.No.2 minus 3(e))
5.
Analysis of drug collections in respect of ttt cards at SI.No.(4):
No. of fortnightly collections made
1
1
2
2
3
3
4
Total
Continuation Phase
Intensive Phase
4
6
8
10
12.
14.
16
5
6
7
8
9
10
.11
No. of TB patients
Cols. 2-5 refer to fortnightly collections in the Intensive Phase (2 months)
Cols. 6-11 refer to monthly collections in continuation phase (3rd to 8th month).
Each monthly collection is counted as 2 fortnightly collections.
6.
Final follow-up examination of smear +ve patients at the end of treatment
period:
a) No. of patients for whom smear was examined
F
' I
b) No. of cases where smear was found positive
]
I
Remarks:
Name of D.T.O.
Signature of D.T.O.
Dale:
12
DTP/1
Case-Finding Registration Form
Type of Examination: X-ray/Sputum/Rol! No.
DTC:
Date
Token
Number/
Sputum
Smear
Number
Name
Father's Name
Age
1
2
3
4
5
Use Separate Sheets for X-ray and Sputum
Sex
Complete address,
Including head of the
family, house number,
street (name), hamlet,
main village and post
office, taluk & district
■Referr
ing
PHI
New
Old
OBS
If Old/OBS
previous
film
number
Result
X-ray/
Sputum
CaseIndex
number
6-
7
8
9
10
11
12
(Size of CFRF - Foolscap)
FRONT
DTP/2
REFERRING SUP
1.
Name
2.
Age
4.
Father's Name
5.
Address
6.
Referring PHI:
7.
New I
8.
For old TB patients Case Index
Number
9.
For Out-patients on observation
Previous Film Number
10.
Come back on :
Sex
3.
:
C/o
:
House No
Hamlet/Street :
Village * P.O./Town
Taluk :
District:
;
I
Old I
I OBS I
Examination Required
■
Sputum |______ |
x-Hay
|______ |
Signature of MO & Date
(Size of Referring Slip — 105 mm x74mm)
REVERSE
Results of Examinations
11. X-ray Film No.
New and OBS
Out-patients
OBS
Old TB Patients
D
12. Sputum
Date[ Smear No,| Result
TBP
PLEF
TBHA
Tl
13. New TB patient
Case index No.
14. Remarks (including advice on treatment)
Date:
Signature of DTO:
30
DTP/2
I
STATEMENT SHOWING THE ANIMAL BITES REPORTED FOR THE MONTH OF
DISTRICT: BANGALORE URBAN
SI.
Name of the
No.
Animal Bites
1.
DOG BITE
2.
SNAKE BITE
3.
Other Animal
bite (Specify)
CHILDREN
Male
Female'
ADULTS
Total
Male
Female
Total
Vaccinations
Vaccination
done
in stock
TOTAL
Signature
Remarks
REPORT ON THE MEASLES INCIDENCE OF BANGALORE URBAN DISTRICT
FOR THE MONTH OF
AS ON
SI.
No.
Name of the PHC
1
2
On the day
Name of the
Villages
Population
3
4
Up-to-date
Immunisation against Measles
A
D
A
D
on the
day
5
6
7
8
9
Post Measles complicated cases treated
Respiratory
Uplodate
%of
coverage infection
cover
10
11
12
Diarreable
Mai
Nutrition
No. ofORS
pkts distributed
13
14
15
Signature
STATE GOVERNMENT OF KARNAT
GUINEaworm eradication programme
Monthly Report on Guineaworm situation for the month of
District: BANGALORE URBAN
St
Guineaworm states
Endemic
Deleted
Non-Endemic
FOLLOWING PHC (s) & VILLAGE (s) IN THE DISTRICT REPORTED/RECORDES GUINEAWORM CASE (s)
No. of Guineaworm cases (s) reported
GW status of village
SI.
No.
Name of the PHCs
2
1
C - Child
Name of the villages
3
Female
Male
Old
New
Re-in feet
4
5
6
C
A
C
A
7
8
9
10
.
Total
Corrective
Action taken
11
•, 12
A-Adult
NOTE: 1. The District monthly report should be compiled on similar report from each PHC of the District.
2. This monthly report, even NIL, must be despatched by seventh of following mont, positively.
Signature
DISTRICT : BANGALORE URBAN
Monthly Report of NIDCP (Goitre) Case for the month of
..........
SI.
No.
Name of the PHC/
Institution
No. of new cases of Goitre
detected during the month
Cases already
reported so far
Total No. of Goitre
dases in the Area
No. of cases
treated sofar
Type of
treatement
Remarks
1
2
3
4
5
6
7
8
Signature
profAim a for monthly performance repot
Particulars
No. of samples
received
No. of samples
examined
Normal
Abnormal
1
2
3
4
5
A - Clinical Pathology
BCDEFA-
Haematology & Immunohaematology
Biochemistry
Bacteriology
Serology
Water Analysis
CLINICAL PATHOLOGY
1.
Urine Analysis-
2.
3.
4.
Routine Complete
Food Analysis
C.S.F. Examination
Semen Analysis
B - HAEMATOLOGY & IMMUNOHAEMATOLOGY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Complete Hacmogram
R.B.C. count
Hamcglobin
TC / DC
ESR
Platelets count
Bleeding and clotting time
Malaria parasites & Filaria
Absolute Eorinophil count
Blood picture
Others
C - BIOCHEMISTRY
1.
2.
3.
4.
5.
6.
Blood sugar
Blood Urea
Serum Cholcctcrol
Serum creatinine
G.T.T.
Bilirubin & Biliverdin
3
W2
7.
8.
9.
4
5
Blood Calcium
Serum Uric Acid
Olhcrs
D- BACTERIOLOGY
1.
2.
3.
4.
5.
6.
7.
8.
Sputum for AFB
Dipthcria Bacilli
Skin smear for Lerra Bacilli
Grem slain
Vibrio cholera
Urethral smear for Gonococci
Culture & Sansiiivity
Others
E-
SEROLOGY
1.
2.
3.
4.
V.D.R.L.
Widal
Blood Group and RH factor
Olhcrs
F-
WATER ANALYSIS
1.
Bacteriological Analysis :
a)
Borcwcll water
b)
Tap water
c)
Well water
d)
Olhcrs
2.
Chemical Analysis of water
No. of samples collected
No. of samples examined
Positive
Signature of the Reporting Authority
Negative
£
PROFORMA
IN-DOOR PATIENTS AND OUT-DOOR PATIENTS TREATED DURING THE MONTH OF
I.
Type of Institutions :
i.
No. of Institutions functioning
ii.
No. of Institutions Reported during the month :
100% reporting should be ensured)
iii.
No. of defaulting Institutions during the month :
II.
SANCTIONED BEDS:
General Hospitals
PHCs
Total
PHUs
General Hospitals :
Male
Female
Children
Total
Primary Health Centres
Male
Female
Children
Total
Ordinary Health Units :
Male
Female
Children
Total
Period
Type of
Institution
2
1
During
the Month
OUT DOOR PATIENTS TREATED
OUT DOOR PATIENTS TREATED
OLD CASES
NEW CASES
INDOOR PATIENTS
TREATED
DEATHS AMONG
INDOOR PATIENTS
Male
Female
Children
Total
Male
Female
Children
Total
M
F
C
T
M
F
C
T
J
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Gen. Hospitals
PHCs
PHUs
Total
Cumulative
from 1.1.9
Gen. Hospitals
PHCs
PHUs
till the end of
the month of
reporting
V
TOTAL
Signature
FORM - I
Information regarding the working of the P.F.A. Act in 1954 in Bangalore (U)
District during the month / Year
SI.
No.
Name of the
PHC
Source of
samples
drawn
1
2
3
No. of
samples
drawn
No. of
samples
examined
4
5
No. of
samples
found
adul
terated
% age
of
adulte
ration
No. of
samples
examined
by 2nd
Public
Analyst
under Sec.
13(2)
6
7
8
No. of convictions
No.of
samples
varied
No. of
Prosecu
tions
launched
Fines
only
No. of
imprison
ments
without fine
Total
9
10
11
12
13
No. of cases No. of cases
acquitted or pending in
discharged & the court of
reasons
law since
thereof
it is pending
14
15
Total fines
realised
16
w
PROFORMA - n
W
Monthly information regarding the total number of samples analysed, prosecutions
launched etc., with regard to commonly used food articles for the month/year.
SI.
No.
Category of
Food Stuff
No. of
samples
collected
No. of
samples
analysed
No. of
samples
found
adulterated
Percentage of
adulteration
No. of cases in
which
prosecution has
launched
Fresh
prosecution
cases
1
2
3
4
5
6
7
8
----- ..^
L---------------------
1.
Spieces &
condiments
■2.
Edible Oil,
Fats and
Vanaspathi
3.
Milk
4.
Butter, Ghee,
Ice cream &
other milk
products
5.
Cereal &
cereal products
and pulses
6.
Others.
Total
No. of
cases
disposed
No. of cases
acquitted
Cases
pending for
more than
1 year
Remarks
9
10
11
12
13
TOTAL
— ■
Signature
GOVERNMENT OF KARNATAKA
DAILY EPIDEMIC REPORT / JAPANESS B’ ENCEPHALITIS CASES
District:
SI.
No.
For the month :
Taluk
9
1
NOTE: A. Attack
D. Death
Primary
Health
Centre
Names of
Villages
reporting
infection
Population
3
4
5
Compiled on :
Date of
First
No. of cases
Last
on the day
Uptodatc
A
D
' A
D
A
D
A
D ■
6
7
8
9
10
11
12
13
No. of
Houses
Sprayed
Remarks
14
15
ABSTRACT UPTO DATE INFORMATION FOR THE YEAR UNDER REPORT FROM 1ST JANUARY /
No. of
reporting
Villages
Infected
Town
Villages
Town
Attack
Deaths
Total No. of Houses
Sprayed
Remarks
1
2
3
4
5
6
7
8
Total Population :
Total No. of Cases :
■
The above daily epidemic report should accompany .the details of case i.e., 1. Name, 2. Address, 3. Age, 4. Sex, 5. Date fo Attack, 6. Dateof Admission, 7. Date of Discharge, 8. Details of blood
samples collected for serological examination etc.,
Signature
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FORMAT
MONTHLY REPORT FORMAT FOR RABIES FROM DISTRICT / ID HOSPITAL
TO STATE HEALTH DIRECTORATE
1.
Total number of animal bite cases
Dog
2.
Total number of cases given post
exposure vaccination and serum
ARS
3.
Total number of cases with neuroparalytic
complications following NTV.
4.
Total number of cases sensitive to ARS
5.
Total number of deaths due to
hydriphobia/rabies
■
Wihtout
Vaccination
Other animals
NTV
TCV
After
Vaccination
~
-------------------------------------------
J
INSTRUCTION MANUAL FOR MONTHLY REPORT FORMAT FOR RABIES FROM DISTRICT/
ID HOSPITALS OF STATE HEALTH DIRECTORATE
1 I
1.
Besides dog, other animals can be cat, buffalo, monkey, mangoes or wild animals. •
2.
ARS - Hyperimmurii^Qtirabies serum of equine origin.
NTV - Nervous Tissue Vaccine.
TCV - Tissue Culture Vaccine marked as Rabipur, Vcrorab or HDCV.
3.
Neuroparalytic complications includes paralysis of leges, difficulty in micluralion and/or'evacualion or temporary
paralysis of one or more spinal or cranial nerves.
4.
ARS can cause hyper sensitively reactions therefore it is given after skin sensitively test.
INVENTORY OF VACCINESAND SERUM
B.No. Item
Unit
1.
Anti-rabies vaccine
ml
2.
Anti-rabies serum
ml
Consumption
Bal. stock
Stock for month
Signature
Remarks
3
INTEGRATED CHILD DEVELOPMENT SERVICES
Monthly monitoring report of project advisor (MO I/C 1’IIC ) for the month of
1.
2.
3.
4.
5.
6.
7.
8.
9.
•.............. 1
Name of the PHC
(a) Name of me 1CDS Project
(b) Type of Project (Please Tick)
(Rural/3 ribal/Urban)
District
State
Total No. Sectors in the PHC
Total No. of Sectors Reported
No. of AWS in the PHC sanctioned
Functioning
Reported
Population : fit PHC
(ii) Reported AWS (All Sectors)
Total No. of Sectoral level training courses organised by all the M.Os
(a) Topics Discussed
(b) No. of participants (All Sectors)
No. Trained
No. in Position
Staff Position
No. Sanctioned
(a) Medical Officers
(b) LHV s/HAs (F)
(c) ANMs or MPHWs (F)
(d) AWWs
10. No. of AWs visited by all the MOs for health check up
II. No. of AWs where supplementary Nutrition was distributed:
More than 15 days
Less than 15 days
O days
12. .Total No. of Malnourished children in the reported AWs (Please Tick)
the method used: weighinent/Tricolor tape)
i) Grade II Yellow
.-.........(ii) Grade III
(iii) Grade IV.............
Total
No. of members advised ORT
13. Total No. of children who had diarrhoea
14. Population break up in 0-6 years, age groups of children as reported AWs
(i) 0 to below 1 year (ii) 1 year to below 3 years (iii) 3 years to below 6 years
(10-11 months)
(12-35 months)
(36-71 months)
(iv) Total 0 to below 6 years (0-7 I months)
15. Immunisation performance figures to be filled in from the available informalion at (he
PHC (al reported under 11PI for children below I year)
Total No.
Immunised in
the PHC
In the report
ing month
Total since
1st April
Percentage
DPT/POLIO
BCG
1st
2nd
3rd
Tetanus - Toxid
Booster
Booster Dose
Measles (Prcg. Women
Doose
1st
2nd
-216.
'
17.
18.
I
19.
Total since last
26lh >1 -cember
(Cumulative)
No. in the
reporting
month
Births and Deaths date :
Nature of event
Live Births
Still Births
Deaths 0 to below 1 year
(0-11 mon ths)
iv)
Deaths in age group 1 year
to below 3 years (12-35 months
v)
Deaths in age group 3 years
to below 6 years (35-71 months)
vi)
Total No. of deaths of
Pregnant women during delivery
Total No. of pregnant women in reported Anganwadies
Lactating women: (a) Total No. in the reported Anganwadies.....
(b) Total No. received mother & child welfare pamphlet
Supplies position - Tick mark the correct answer:
i)
ii)
iii)
Vit. A
Position
Iron &
Folic acid
Tablets
Drugs
for
AWs
BCG
DPT
Polio
Measles
•
Adequate* *
Inadequate
*
Indicate adequancy as per monthly requirement in reference to total requirement for the
target given to PHC
20.
Fund from Social Welfare Department for Puel (Please Tick)
Received/Not receieved
Medicine kits for AWWs (please Tick) Receive/Not Received.
21.
Note: Please fill all the information. Do not keep to space blank.
Write actual numbers or dash, in bold letters
Signature
Name
PHC
Full Adress
Note :
...........................
..........................
Copy of MMR should.be sent to the state co-ordinator and Chief District
Adviser within a day after the end of the each month under certificate of posting.
No. of A/W visited by MO.....
■ No. of Children Examined..;,..
No.-of Children defective .
' No. of Children referred
.
No. of ANC Regd. D.M.
Vaccines
No. of AAV visited by LHV..
No. of AAV visited by ANM
No. of children Treated
No. of ANC on hand
J
INTEGRATED CHILD DEVELOPMENT SERVICES ADDITIONAL INFORMATION ."DECT.
*•
Taluk
CHC
1)
Month
<•
Causes of infant children and maternal deaths
Infant
Children
Metemal Death
1
2
3
1
2
3
1
2
■
3
2) Health Check up particulars
'
‘
' SI.
.
Type of
On
No.
No. found
■No.
No.
No.
Beneficiary
roll
Examined
defective
Treated
referred.
,L
Children under
'6 years
*
With Details
• 2- • A.N.C
3.
P.N.C
4.
Others '
•
-
Total
*
Details
3)
Co- ordinated Work
(a)
No. of Anganwadies visited along with
M.O. for Health Check up by....
(b)
No. of SLM attended by..........
CAD
CAD
AD
AD
DA
£
DA
CDPO
ACDPO
MS
LHV .
-
CDPO
ACDPO
-
ANM
-
Other Spesity -
Other Spesity -
Total
Total
Place of SLM Conducted
■ <w
CENTRAL TECHNICAL COMMITTEE
integrated bother child development services
FORM Al-3
(MMR proforma for &ural tribal and Urban project)
(From 1st day of the last day of month under Report)
Subject: Monthly monitoring report for the month of--------------- 1999*
PART:I
(To be filled by CDpOS/Statistician Assistant of the ICD project
1. Name of the State - - — - ------- - -
Code ——--- ----- -----
2. Name of the District -—------ - ---------
Code
3. Name of the project
——-
Code ———
—
Bock/PHC/CHC
4. Type of project------------ ----- ------ Rural/Tribal/Urban
5. No of New PHC/Sectors in the block Area —--------- ------
£
6. Category of project central/state
7. Year of sacntion------------------------ Year of operational-------------------8. Portal Address of CDpOS------------------------- Postal Address of Pa
Pin code
Pin cods
No. of AWS
No of AWS
9. No of AWS
Sanctioned--------------
Functioning---------------- Reporting---------------Population Reported AWS all sector®/pro
10. Population sector/project
11. Total population of AWS all age group (0—71 month)
Children 0-6 years of age ------------------ —
Below 6 months
12. Women
6 months-lYrs
1-3 Yrs
3-5
5-6
Nursing (first sLx months of lactation)
pregnant
1 3. Reported births and deaths
Births
Live birth----------------- still birth------------------------Deaths
Below 1 yrs----------------1-3 yrs----------------- 2-5 yrs---------------5-6 y§s-----------------
1 4. Deaths of women
During pregnancy
During Labour
During PNC(Witnin 42 days)
15. So. of AWS provided Snp in the month
0 - day
5-14 days
16-20 days
21 days & Above
16. Supplementary Nutrition in all reporting AWS
categary
Total So.
of eligibel
Total No. of
enrolled
Ho. received
SNP for. 15 days
or nose
A) Pregnant
Lactacti ng
b) Children
6 months
6 Yrs of age
17. Total No. of children who had diarrhoea--------------—
No. of Mothers advised ORT----------------- —
18. Classification of Nutritional status No. of children
Weight (sum of all weight)
With Normal Weight-----------------in Grade-1----------------in Grade-II
---------- -------
in Grade-Ill
-------- ----------
in Grgde-IV
....
Total
----------- -——
19. No. of sectoral level meeting of the Health and Non-HealtH staff
organised by CDpO by active involvement of p. A and sector level
advisors
PARTICIPANTS
health staff
ANM
MOS
Da
aupervisers
ACDpO
.LHV
OTHERS
ICDS -staff
AWWS
CDpOS
OTHERS
20. Topics of continuing education (Health)--------------- —
21. No. of AWS visited by - (apart from health check-up)
ANM
LHV
MS
ACDpO
MO
Da
CDpO
OTHERS
DI ST LEVEL
PUBLIC
part - II
22. Staff position
S.No
Staff position
Health staff
No. sanctioned
No. in position
No.Trained
1.'Medical officers
2. LHVs _
3. ANMs
4. I CDS staff
CDpO
5. _ACD?O____ ____ _________ , ~ _
6. M.S
. Z’_A*W__________________ .
23. No. of AWS visited by all the MO’s for Health checkup
a) Visits during health check up
ANM
Da
LHV
MS
ACDpO
CDpO
OTHERS
24. Immunisation performance require to be filled in the from the
available information at the sector/project( as reported under UIP
for children below 1 year)
Total No. of
immunisation
in the sectors
project
ELA
OPT
BCG
POLI 0
TT
Prg women
ist 2rai 3rd Booster 1st 2nd 3rd boos- 1st 2nd 3rd
Dose
tar
doss
'
in the reporting
month
Total since
S s t Apri 1
JOINT VISITS
MS + IHV
DA + CDPO
DA + ACDpO
MO + CDpO
MO + ACDPO
CDA + AD
25. Supplies position tick nark the correct answers
Position
Vit A
Iron*
polio
acid
Anti
worm
Drugs
for
AWS
~
BCG
"
DJT
VACCINES
~ ~
POLIO MEASLES
~ ~
TT
Ad e qu ate
Inadequate
In adequate adequancy as per monthly requirement in reference to total
requirement for the target given to sectoral / project
26. Funds from social welfare Department for pOL (please tickj Received/not
received.
27. NOTEs- Please fill all the information Do not keep any space blank
write actual number of sill instead of Dash.
A
"
28. PHC meeting held on-----------------
Signature ----------------
Name
—----------
Sectoral/froject --------------
Full Address
Date:
NOTE 1) Despatch the report to central cell within eight days after the enl
of each month.
2. Copy to MMR should be sent to the state co-ordinator and chief
District Adviser within eight days after the erxi of each month..
District wise percentage
Dis t
Code
1 .
District Naae
^yrs
Rep.Pop
g*
SMNSMN
viij. j_ui
2
5
4
5
of HtH & Sill
M«N
/v
6
7
8
under ICDS pro,i;raaae
MMN
Live
Bir th
Death
fa
du oil
itd.bc
u
9
10
11
j
12
for
the nonth
of Deceaber-99.
R
1yr pRGW
p
PRGWLA3?W
yx
U ®
/°
13
14
15
16
17
18
19
72) *
n)75~c) OV«~c) pdOCkJ^g yZ5OC5
c30c)<^)o
UjflA
l3G52)Os3>J
r3c5UO~c)r3
eeV :
OCTDO 0^^000 rfO'
~_______ —53.06-
td
o
oO
}—3
3 *4 F"CJ OD
__
nJ "c)^c3
rtoo
iorts
aoaa
rtuo
l-p 33,f -2
33,F
A<3
S'Jq^C’o
D
_5.c9Jr5_ __ •__
2^ 3sf — 3 S^F
O7>37)j?3'J
330
__
.Sod.
Lki “ 3ot53
^ra«S
c^d-tukjj^,
Aitdrssj.
50 see)
100 sod
50
3u0
dcfa uwd <?>c^ 330^0
sooJj 50
nyo
100 aoc 100
3od(,
30J
3j0 50
100
3UrJ SCO
ncra„ edO7>C.0j 3U3U_, JJUJOU £cra,>,n> t<>3-?)OOVj
P =d„-
INTEGRATED CHILD DEV ELOP MENT SERVICES
FORMAT -4.
DISTRICT ADVISORY MONTHLY MONITORING REPORT FOR THE MONTH OF
1. Name of the State.KARNATAKA District DHaRWAD
2. Number ef sanctioned ICDS Project in the District
3. Number ef operational ICIS project under your change
....
4. Number of project Advisers under your change
.
5. Details ef monthly Monitoring reports received frem the PHC of
Operational ICDS Project under your charge.
Name ef
ICDS
Project.
Name of
PHC
Date of
Date af
PHC
level
MUR checked
meeting
cc despatched.
continu
ing e du
cat ien.
Remarks about the (a)
To pics
dis cuss ed
(Title
only)
No.of par
cipants
L3D/LHV/
CDDO/iS/
Others.
Co-ordination wita CDPO and (b) Food '
quality at AiV Centre
GOOD/ACCEPT ABLE/POOR
Signature
.
District Advisor
Date;
Note;1.The manthly meeting in all ICDS Projects under your charge
should be completed within 7 days after the end of each monh.
2. The uLih should be submitted to Central Cell within 11 days,
after the end of each month.
3. Copy of MJR should be sent to the State Ce-erdinator within
11 days, after the end of each month.
INTEGRATED CHILD DEVELOPMEN'T SERVICES
FORMAT -5
Chief District Advisor's Monthly Review Report for the month of
1. Name ef the State
District
Population......................................
. .
2. Date af District level meeting (including ICDS)
- -
3. Number of ICDS Projects in the District
(a) Sanctioned
( b) Operational
.
.
........................ , ,
<1. Number of ICDS health functionaries in the District.
(a) District Advisors
..... . .
.........
.
(b) Project Advisors
Name ef
District Advisor.
5.
Nam e ef
Proj ect.
Name of
Pre j ects/PHCs
under his charge.
No . of Project
Adviser report:
despatched by
PAs in the
district to
Control Cell.
Immunisation perfermance in the district (These figures are to ’
filled from the available information for children, below,
1 year under DIP at the District Headquarter).
No.
immunis ed
in the dist.
BCG
DPT. doses. Polio doses Measles
1st 2nd 3rd 1st 2nd 3rd
TT to Pre,
wot?e'
1stdase/
2nd dose.
1. During the
menth.
ii.Total
since 1st
April.
6. Remarks under the following events as compared to last month(Pl.t;
a.Malnourished Children
Grade II
Increased/^eoreas ed
b. Diarrho ea.
Grade. Ill &TV
Increas ed/Deereased,
c.Total Deaths
Increased/Decreas ed
a.o to
1 year
Increas ed/Decreas ed.
3 year
ii. 1 to
Increased/Decreased
Increas ed/Decreas ed
6 years
rii.3 to
Increas ed/Decreas ed.
iv. Preg. women during delivery
Increas ed/DecreaSed.
7.Remarks regarding food quality at
AW Centres.
3.Number of participants in Distric
Good/Acceptable/Poor.
level Meeting.
a) Di s t ri c t Advi s s rs
b)Project Advisers
c) CDPus
d) Diat,Social "’elfarc Officers.
e) Others
MONTHLY REPORT' OF
DISTRICT? MYSORE
SI.. ITnme of the THC/'
No. Institution
BREAK HP
1? S.C.
: 2> S.T.
No. of £cases
of Goitre cases
detected-during :
the month .
.
Cases. Total No.
already of goitre
report- cases in
ed so
the area
far.
No. of
cases
treated
Type of
Treatment
.
MINOR CG-PTONITY
3) Musi in
4) Christain
5) Sikh
6) Budd is t
7) Jains
Totals
8) Others
Total from 1”8
■ Sathya--
District Health and Family
Welfare Off ice r Mysore.
Monthly Report of Goit?e Cases for the Month of...
■district i
si.
No.
1
------------ ---------------------------------
•
Name of the
PHC/lnstitutions.
2
/ ■
r •
Break - up
SC.
ST.
3
4
MINOR COMMUNITY
Mus
lim
Chris
tian
Sikh.
Budhist
Jains.
5
6
7
8
9
Qthers
10
No. of New
cases of
Goitre
detected
dur. month
11
Cases
already
reported
so for
12
Total
No. of
Goitre
cases
in the
area
No. of
cases
treated
so far
Type of
Treat
ment
13
14
15
(I o be submitted by 25th March to. the State Family Welfare Officer and Deptt of Family Welfare,
MOHFW, GOI, New Delhi through NICNET)
FORM 4
DISTRICT ACTION PLAN
A.
General Information
State
District
No. of PHC in that District
Population of the'DTsfficfT
Birth Rate of District / State
SI.
No
lh.
_____
Code : I
Code: |
I
~]
...Services.- _
Year
Eligible couples
(as on 1st April)
Performance in Planned performance in
last year
current year as compiled
from PHC & FRU plans
Antenatal Care
Total No. of ANC cases registered in the Distt.
2.
No. of high risk pregnant women - Treated
3.
No. of TT dose given
TT1
TT2__________ ________________________ ____
Booster
4.
No. of pregnant women with anaemia treated
5.
No. of pregnant women
given prophylaxis with I FA tablets
6.
• Total No. of deliveries in the District
-
—
Natal Care
•
No. of home deliveries by ■
a) ANM/LHV_________ •________ '________ ‘
b) Trained birth attendant
c) Untrained birth attendant
J
■•
—-------------------------8.
No. of institutional deliveries
a) At District hospital
b) At FRU
c) AFP HU
3) At sub-centre
g
No. of sick new borns
Treated
Referred
10.
No. of MTPsdone
Neonatal Care
MTP
----------- - ----------- ----
[ruiiii o coma.)
RTI / STI
11.
M
F
No. of cases detected
- Treated—-----------------------------------------
M
F
'—-
Immunization
12.
No. of infants immunized (0-1 years)
BCG
DPT-1
DPT-2
DPT-3
OPV-O
OPV-1
OPV-2
OPV-3
-
■
Measles
13.
No. of children immunized
(more than 18 months)
DPT Booster
OPV Booster
14.'
No. of children immunized
(more than 5 years)
-DT - •
15.
No. of children immunized
(more than 10 years)
16.
No. of children immunized
■'more than 16 ye a ts )______
TT
17.
No. of children given IFA small
(below 5 years)
Vit. A
18.
No. of children administered Vit. A
(9 months to 3 years)
a) Dose 1
b) Dose 2
c) Dose 3 - 5
ARI
19.
No. of cases under 5 with pneumonia
b) Referred
Acute Diarrhoeal diseases
20.
No. of cases under 5
Treated with ORS
-— —
-—--
(Form 4 contd.)
21.
22.
Family Planning
Male Sterilisation
a) Conventional
b) NSV
----- —
Female Sterilisation
a) Abdominal
b) Laparoscopic
-
23.
IUD Insertion
a) by aNM
b) By PHC doctor
c) By FRU doctors
d) By District hospital doctors
24.
Oral Pill Users
25.
Condom Users
»
Material & Supplies
SI.
No.
Items
Unit
" Qty. used in
previous year
Stock position
on 1st April
Additional Quantity
required in
Contraceptives
2.
3.
4.
5.
Nirodh pieces
Oral Pill Cycles
IUDs
Tubal rings
Dai Kits
——
k Vaccine Doses
*DPT_j________________ j
7.
_OPV~
:
----------------- - —
8.
TT
i
9. ~BCG—----------------------- r----10. ' Measles'"
—---------------DI------------------------- ------ t------- —
11.
6.
IFA Tab, large
IFA Tab. small
v it. a solution
ORS Packets
Cotrimoxazole
16.
17.
Tab. Paediatric
RTI / STI Drugs
;
---------------------- - —
—
Prophylactic Drugs
J 2.
i J.
TV
1~5.~
'J
—---------------—
—
—
---------------
(11> be subni’lted by 25lh of following month lo Sialo Family Welfare Department and Department of Family
Welfare. MOHFW, GOI New Delhi through NICNET ’
FORM 9
CONSOLIDAI ED MON Fl !l.T REPORT FROM DISTRICT 10 STAT E I CENT RE
Gsurnal
.
I
2.
Slate
7AD<Z^.
Dislrict—C^2_T,JkP?3 T-------------
3.
Population of District
SI.
No.
5.
pppoiting for Hie month of
Eligible Couples (as on 1st April of the year)
Service
1
ANC Registered
II
Ants Natal Chock-up
Pregnancies
Cumulative till this month last year
Cumulative till this month (his year
who have received 3 check-up
How many received
TR
Booster
___________ IFA_______________
------------- -—
1''gh risk Pregnancies
-PHC
CHC
pnu
—
District Hospital
Urb-in Dispensary
________ tTC---------- --------- 7-------------------- -------------- - —
Complication
Referral
iii
Doliveiios
Total No doliverod
By
Trained attendant_______________ —
ANM ' LHV
Ins'ilutional Deliveries at_________ —-------------- Sub-centre
pnc
Fnup———
tlisinci
Urban Dispensary
PPC
Complications
Referred
IV
Maternal Deaths
V
Pregnancy Outcome
_______ During Pregnancy__________________
During Delivery
Within six weeks ol Dehveiy
___
No. ol live births
No of still bit ll is
Order of birth
1st
2nd
3rd and 3 r
Weight ol new l>oin
<2 5 I'm
> 2 5 Kg.
CCC-fihl
j|?/.
_____________
VI
Noo-Nnlnl C.t o
VII
Pent Nalnl
Who hav < rcooi'.ed 3 chock-ups
VIII
rfi/sii
No of clinics in District
No. of male cases heeled
No. of lemale cases treated
Referred to
PMC
FRU
District
IX
M1P
X
Immunization
No. of Govt. Hospitals and others with M TP facilities
No. of Ml P cases done
Infants 0 Io 1 year
__________
- BCG
______
>
Sick new lx?rn cases
Relorrod
F
7"
- -221 1
c DPT 2
DP I 3
- OPV 0
- OPV t
■ OPV 2
Measles
- Full Immunisation
Children more ihan 18 months
- DPT Booster
- OPV Booster
- Full immunized
Children more than 5 years
- DT
__ _____________ _
Children more Ihan 10 years
- IT
Children more Ihan 16 years
- TT_______________________________
Adverse reactions reported alter immunization
XI
Vitamin A
—
•
_
Dose I
Dose 2
Dose 3 - 3
XII
Childhood Diseases
•
Vaccine preventable diseases
Neonatal Telanus
Cases
Deaths
Diplheria
Cases____________-__________________
Deaths
Poliomyelitis (Acute Flaccid Paralysis)
Cases
____ Deallis______
T elanus (Olhei*.)
C.isf's
(eailis
____
'.■hastes
Casos
Pneumonia under 5 year ot age
Cases
Cases Ireaied with cotrimoxozole
C-iSr.'S referrers
Deaths
ate Diarrhoeal diseases
Sasm. .reitr-.; with OPS
Chiid (Deaths
".'it.-.in .jne weeK of birin
.V tl’in one week to one month ot birth
V :nm one month to one '/ear ■ •: KiinT
■.’rtt'in one year to five
ntrnception
is cl bid."
tie Sleriisal'on_________________
"-.-male Sleiilisalion
. J?:> insertions
jrai Pills
Juirjorn users
•Ic ol hospitals which did □( least '
1) ^Conventional Vasectomy
2) Non scalpel Vaseclornv
"I -Mxiominai i'ubectom?
■II Lapiuscooic ruDeclomy
I
I
V >
Abortions
VI
Stock position
'/.scene
DPT
In Slock
I
Cui Stock
“CPv
In Sleek
Out Stock
FT
’
In Slock
Ou! Sic :!<
CT
In Sic ;k
Cut Slock
In Sleet-.
Cui Slock
Meash.'s
In Slock
Cui Slock
if ntiTt •! r.onltl)
Contraceptive
Condoms
In Stock
Out Stuck
f.Jial '*!ils~
In Slock
Out Slock
’ IUDs
In Stock
Out Slock
Tiibal Flings
In Slock
Oul Stock
Iron
IFA large
In Stock_____________ ____________
Out Stock
Vitamin A Solution
In Sleek
Out Stock
OFIS Packets
In Slock
Out Stock
XVII
XVIII
Cold Chain Equipment
Staff Position
'..S&’ic/'•>>>'■' -
riT>-)pJ
—
ILR-300
Total supplied __________________ ___
Total not working
DFz-aoo
T.c'.rl supplied
Total not working
ilr - 140
Total supplied
Total nol wotking
UFz-130
Total supplied
Total nol working
Spociiolist in CHd / FR1'
Mo Sanctioned
No. Vacant
No who have received ROH Training
Doctors in PHC
Sanctioned
Vacant
—ANtvis in Sub-Centre
Sanctioned
Vacant
Male 1 Icalth Worker
Sanctioned
Vacant
Lady Hen'b Visitor
Sanctioned
Va-a.nl
Signatui a of
ftislt Family Welfare Officer
—
—
Form AFP - H002
ACUTE FLACCID PARALYSIS SURVEILLANCE SYSTEM
WEEKLY HOSPITAL REPORT
After review of all wards and registry books,
please send this report to the following person every Monday,
so that it will arrive by Tuesday noon:
Name:
Position:
Address:
Telephone:
Fax:
Hospital:
Week No.
Period included in the report
Year:
From
to
Number of Acute Flaccid Paralysis cases identified:
If no cases were identified write zero (O)
Name of person filling out report:
Date report is sent to District:
Approval of Medical Director:
ALL CASES OF AFP IN CHILDREN UNDER 15 YEARS OF AGE SHOULD BE REPORTED
AND INVESTIGATED
Government of Karnataka
Directorate of health and F. W. Services, Bangalore-9
The monthly progress report under the School health Programme during the month of---------------------------SI.
No.
Name of the District /
Taluk /PHC / SC
1
2
No. of School
Primary &
Secondary
3
No. of students enrolled during the
year 2000-2001
Monthly
Target fixed
4
5
1st.
Std.
No. of students medically examined
8
1st.
IVth
Vllth
Total
%
Dental
Eye
11
Eye
Ear
Skin
Vllth
Std.
Nutritional
deficiencies
Others
Ear
No. of
students
referred
12
Skin
No. of schools
visited by Medical
Officers
7
Total
No. of students found medically defectives
9
No. of students treated for the medical defectives
Dental
IVth
Std.
No. of students'
Health records
opened
6
Nutritional
deficiencies
No. of schools supplied with the Medical
kits
10
Others
No. of students immunized
for booster dose of D&T
among the 1st. std. students
13
cumulative
During the
total
month
No. of students immunized with booster
dose of TT during the month
14
Vllth Std. students
During cumulative
month
total
Xth Std. students
During cumulative
total
month
No. of health Education
talks given in the schools
Health Education activities
No. of health education materials
No. ofPTA meetings conducted by
distributed to the schools
health personnel
15
No. of schools
provided mid-day
meals
16
17
No. of schools having urinals and latrines their
maintenance
Maintained cleanly
Not maintained cleanly
21
20
No. of mini exhibitions/film
shows arranged in schools
22
Maintenance of the school
premises
23
No. of
No. of
schools not
schools
maintained
maintained
cleanly
cleanly
18
No. of Teachers
trained under the
School Health
Programme
24
No. of schools
having safe
drinking water
facilities
19
Any specific
activities carried
out may please
be reported in
this columns
25
'S'
.
DIS-
>k:T..Z
■ •o
mo nt
under
a
Upt« the
end of the
month
during the
/ear 3-9
no
riO l, r RO
1
b) Cured
o
,) Nev/ TB patients
detected
No
2
b) Sputum Examination
through PHCs
3) 3 l I ?I D?I ESS;
C-tract Operation
No
M Al. -.RI A:
a) Blood Smears taken
i'V_ _
b) Malaria Positive
cases
No
5) GO IT RS C 13 NS :
a) Detected
MINORITY COMMUNITIES:
Nev; IB cases detected
>rgjn/71294/-
DiSTRlCT HEALTH AND F.’..OFFICER,
MYSORE.
xtp.j.nxk.jorj
Year:
Month:
i
"
;
1
-.
1
--■
■
PERFORMED:
----------------------------------------------
1
. rted
3. u
c • ■ ; (Jirodh)
-LX » V
0 0 .‘ • V?■• • X■ o
3. Xerlisation Deaths
6. IiX_XIZAfION:
a) INFANT3 IMMUNISED^
i)
ii)
i i i)
iv)
J
!
1
_
b) D.T.
_ II
c. T.T. (10) - II
d. T.T. (16) - II
c) T.T. (PM) _ II
f) Booster
g) Children Beneficiaries
h) Mother Beneficiaries
7. UNIVERSAL
PRIMARY iiEALT.I CARE:
------------------------------------------------------
'
[
!
1
1
i
i
i
6. MINORITY COMMUNITIES:
a. New TB Cases detected
1
1
1
1
1
(b
0)
1
I
........... . '
1
__________ 1
t
... _
1
1
I
1
1
1
1
1
i
1
1
(
1
.
1[
1
1
___
1
—
------------------
1
.
—
1
I
1
1
1
1
1
1
1
i
1
1
1
1
f
I
I
l
I
i
j
i
i
i
i
_ _
—-------------
1
1
1
1
8. CSXR0L_P ROGRAMMES:
1. LEPROSY:
a. Detected & Treated
b. Cured
2. TUBERCULOSIS:
a. Neu TB Patients detected
b. Scutum Exam,through P.ICs
3. BLINDNESS:
a. Catract Operations
4. MAL/.RI.-.:
a. Blood Smears taken
b. Malaria Positive Cases
5. GOITRE C/.XS:
a. Detected
b. Cured
_
1
1
1
-----------------
1
1
!
I
1
1
a. Primary Health Contres
b. Community Health Centres
j
i
]
>
1
J
1
I
I
_______ _____
.—
----- •
1
1
1
1
i
j
!J
----- ---- -----
1
1
i
...
.______
1
J
D.P.T. _ III
Polio
- III
3. C. G.
Measles
------ --------
——
.
I
;
(1
. —.
.
No nt h
I
I
*-■
j
i
11
j
J
'[
(/ j
1
O
1
T
I
1
I
>0
3 chcr:?? 7 3’i j- scheme
i
i
3aklo g
..chmnt/Cases 1
D.tring Month *
l
1
•
------------]
1
!
1
District:
i
i
i
I
i
i
II
1
1
1
1
1
1
1
1
1
1
!
|
1
1
1
1
1
1
1
1
1
1
1
1
1
!
1
I
1
1
1
1
1
1
1
■“
1
1
1
1
1
1
1
1
1
1 ■ "
j
1
1
I
I
1
1
1
1
1
1
I
I
1
1
1
1
roto:
A.-TICTAL FRO.'
iOFTROD 07 BL II
MONTHLY MONITORJL v 0? C'.TRACT SURGERY
FOR EACH FACK.ITi .'ITi’IE TIIE DISTRICT
State■
District;
MY S 0 R E
Facility
Month of Reporting?
__ L............. i
Month
Year
No. of camps held (For Di'IU/CMU/NGO)
CATRACT I'ERFORMAKCEs
By method of Surgery
Number of Operation:
1/I0L
F.Y ?.LE
By Eyes affected
Total Catract Operations in the month;
Commulative total for the year:
Target for the year:
Copy submitted to:
Dr. Mrs. J o s e,
Deputy Director General (0)
Nirmah Bhavan,
II2Li'_. P B Jell. J. •
DISTRICT HEALTH AND F.U. OFFICE .,
i'Y SORE.
brgm/1 99§/-
PROFORMA
IM DOOM PAIIEIItS AND OU I DOOR PA 111=1'115 I REA I ED DURING 71 IP MONDI OF ................................
1
Type of Institutions:
II
No. ot Institutions
1
No. ot Institutions re-
General 1 lor-pll.ilr.
Total
PHU'S
PHC's
functioning
poiled during the month
■ ■ i!1J)il.:.':i r-
(100% repot ling should
be ensured)
ii
No. of defaulting institu
tions during the month
II
SANCTIONED BEDS:
1.
General Hospitals
ii.
Piimary Health Centro
iii.
Primary Health Unit
Total
Children
Female
Male
Out Door Patients Treated
Old Cases
Type of Institutions
Period
1
2
During
General Hospitals
the ■
PHC's
Month
PHU's
New Cases
M
F
C
T
M
F
C
3
4
5
6
7
8
9
T
10
Total
Commulative
General Hospitals
From.......
PI IC’s
!
till the end PHU’s
o( the month
Total
reporting
INDOOR PATIENTS
2
1
During
General Hospital
(he
PHC's
Month
(PI lU's
DEATHS AMONG INDOOR PATIENTS
M
F
C
T
M
F
C
3
4
5
6
7
8
9
T
10
Total
Commutative
Gen. Hospital
From.....
PHC's
till the end PHU's
of the month
Total
i cpOHh »g____
•rk-AAI’rofotrnn rls
(Seal and Signature)
r
MONTHLY STATEMENT SHOWING INSTITUTIONAL CASES
AND DEATHS DUE TO COMMUNICABLE DISEASES
District
Institution
1.
Name of the Slalc/UT
:
2.
Month/Year
;
3.
Total Number of existing Institutions for the month in the State/UT
:
4.
Total number of reporting institutions in the State/UT
:
5.
Total Number of Defaulting institutions for the month in (tie State/UT
:
6.
Reported cases and Deaths due to Communicable Diseases
SI.
1
Patient treated
OPD
Name of Diseases
No.
:
M
F
C
M
IPD
F
Deaths
(IPD only)
Total
C
M
F
Total
C
Acute-Diarrhoeal Diseases
(including Gastro Enteritis & Cholera)
2
Diptheria
3
Acute Poliomyelitis
4
Tetanus other than Neonatal Tetanus
5
Neonatal Tetanus
6
Whooping Cough
7
Measles
8
Acute Respiratory infection
(including Influenza & excluding pneumonia
9
Pneumonia
10 Enteric Fever
11
Viral Hepatitis
-
12 Japanese Encephalitis
13 Meningococcal Meningitis
14 Rabies
15 Syphilis
16 Gonococcal Infection
17 Pulmonary TB
18 All other Diseases treated in institutions
excluding above mentioned diseases
Tct-1
Please take care not to include simple dog bile cases.
Including communicable & non-communicable disease.
(Seal and Signature)
110NTIILY .GUIIW.70IM RE i 'ORT
FOR THE MONTH OF_
199
hiq-'talui:_______________________________ __________________
MYSORE.
.■
DISTRICT.
S tn te: K A R 17 A T A. KA.
____ ___________
MONTH:
_( Nil if no cases)
Ho. of cases
No. of rumours:
Rc ce ived
..
........
Investigated
3) Probable Case:
l-Iame
i)
_
~__ ___
Age ________________ ____
ii)
Sex
iii)
‘
iv) complete Address:
Sourece
v)
of water used for drinking
v i)Othcr family Members''
.
Case
vii)
detedgd on:
No.of
viii)
Primary Health Centres Sub-Centre
OFFICE OF THE DISTRICT HEALTH AND FAMILY './Ex'-FARE OFFICER'^ MYSORE.
No.IIS/
/ 99-2000
Dated:
To,
1) The Joint Direc tor(DDC cc CM.d).Directornte of Health and F.W.Services.
Danpalorc,
'
'
2) The Deputy Director(Helni).;’IOD,22 ob-mnath Marg, Delhi- 110054.
5; Dr.N.G.IIaraynna,Enidemiolo.r;ist, OTST, c/0 District Health andF.V/.
Off ice,Gulbnrga.
3 a th
'
{
__ ..a
>.i3jc)0J
ad
' ' 20*' oovritf uu-aro;/'w— 1/
XuFJa
«300:
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KO-T L" C-‘‘. NEA ’'0 ?' ••E'-THT
199
ir: iiort:: of
District:
State:
!-C A R N A ; A K A
Month?
1) Mo. of Cases?
_______
(Nil if no cases)
2) No. of rumours:
.„„
Received
Investigated
................. .........
5) Probable Cases
i) Name
ii) Age
iii) Sex
......................................
iv) Connie-to Address:
.........
v) Source of water us A for drinking:
vi) Other family Members:
.. .
„
.
..............
vii) Case detected on:
viii) No. of Primary Health Centres A.
!
OFFICE OF TIE DISTRICT HEALTH AND FAMILY WELFARE OFFICER, MYSORE.
No.HS/
/$ -9
Dated:
To:
1. The Joint Director ;DDC A C'-'.d) , Directorate of Health andF.W.
Services, Bangalore.
2. The Deputy Director (Helm) 1TICD, 22 Shamnath Marg, Delhi. - 110 O94i
3. Dr. N.G. Hamyana, Epidemiologist, G7EST, c/o District Health and
F.W. Office, Gulbarga.
brgr/299^-
DISTRICT HEALTH AND F. ’. OFFICER,
KfSORE.
DTP/3
Case Index Register
—
Case-index
Number
L_—-—1
—--------------
e
Name.
Group No.
Date &
Film No.
Date & Sputum
Smear No.
Remarks
2
3
4
5
6
DTP/4
INDEX GARD
1.
Name
4.
Group No.
2.
Father’s Name
5.
Case-index No.
3.
Address
C/o
6.
Age
House Number
8.
Remarks
Hamlet/Street
Village & P.O. Town
Taluk
(Size of Index Card — 105 mm x 74mm)
31
7. Sex
TUBERCULOSIS TREATMENT CARD
1. Name
2. Father's name
3. Age
Husband's name (if married)
4. Sex
5. Index no.
8. Previous treatment (Drug and duration)
'■1
6. Address c/o
(in full)
DTP/5
Under DTP
7. Occupation
Outside DTP
Disease classification
Smear Pos.
Extra Pul [
Suspect
Specify
Pul. TB
V
9. Current I I I
Land Mark
Date
Place i
Change in address
Diagnosis
Place ii
Place
Date
co
m
Intensive Phase (Tick Regimen Prescribed)
10. Type New
of
Re. 1 1 1
patient Trnsfrd
11. Result of examination
Month
Date
Result
Smear No.
X-Ray No.
Date
Ri
|
|
|
1 S
= 0.75 g
|_____ | H
= 300 mg
T(E) = 150 (800) mg
(2 Months daily)
Result
Rb
6
12 and more
cn
co
ID
m
Sig. M.O.
__ _
Day
-------
1
\
2
3
k_ I_
4
5
6
7
8
9
—
10
11
12
-----
13
14
-AMCC
15
16
17
18
19
20
21
22
23
24
25
26
27
28
2:
m
o
12. Intensive Phase (Make entries for starting R2 alsojcheck the strength of tablets every time before issuing
Month
F
O
S = 0.75 g
H = 300 mg
R = 450 mg
Z = 1.5 g
(2 Months daily)
H
= 300 mg
T(E) = 150 (800) mg
(2 Months daily)
3
Sig. M.O.
E = 80 0 mg
H = 300 mg
R = 450 mg
Z = 1.5g
(2 Months daily)
Sig. M.O.
R2
0
Ra
Sig. M.O
29
Sf^F
30
31
Continuation Phase flick Recimen Prescribed) check the strength ci tablets ceioru i^umy
300 mg
H
H
Reg. 1.
Month
Day
'
T(E) = 150(800) mg
T(E) = 150(800) mg
daily
daily
daily
.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
\
\ S=0.75gm
, H=600 mg
\
I R=600 mg
I
6 months
Sig. of MO
10 months
Sig. of MO
Rog. B.
Reg. A.
= 300 mg
T(E) = 150(800) mg
10 months
Sig. of MO
H
Reg. 2.
= 300 mg
19
20
21
22
1
Sig. of MO I Bi-weekly 4 months I
23
24
25
26
Total collodions
(for DTC use only)
27
28
29
30
Sig. of S.A.
with dato
31
r?;~y-’ k'jJ/— 1
>'L,'n'-'-^‘<z--yiC,-y'.''L;Zr'dr22,'.-p‘A- ~.•<^1f
FRONT
DTP/6
IDENTIIY CARD
TB CAN BE CURED
1. This is an important document to get
treatment.
2. Don't lose it; it lost get a new one
issued.
In Local Language
3. If you collect the drugs on the due
dates and take the drugs regularly,
then only you can be assured of a
permanent cure.
4. Follow the instructions given about
treatment and subsequent
examination.
(Size of Identity Card: Post Card — 140 mm x 90 mm)
REVERSE
1. Name
Age:
2. Father's Name
Sex:
Sputum Smear No.
3. Film No. & Date
4. Index No.
5. Drug Regimen
6. First Follow up
Month & Year
Film No./Sputum No. & Date
9. Come back on (date)
7. Second Follow up
Month & Year
Film No./Sputum No. & Date
8. OBS Out-patient
Film No. & Date
34
Date
_'■ ‘J -.*/•••:.)?£•
DTP/7
INDEX NUMBER SLIP
With reference to the MRT received from your centre for the month of
19
the following details are intimated.
A. FOR NEW TB PATIENTS
Name of the patient
Sputum Smear
No.
Date
X-ray Film No.
Case Index
Number
B. FOR OLD TB PATIENTS
Name of the patient
Case Index
Number
Details of previous treatment
Regimen
Date of
diagnosis
Number of
collections
Any other information:
TO
THE MEDICAL OFFICER
District TB Officer
DTC
(Use as an Inland Letter)
35
cAb
-0
uO'-‘vJJ_cUU>JO<L) oU"a^ra "307)21
ydxJT)
300
So?)® uBeG 3u3Uj QfOdoa SUOco 5^07)00030
TjaSFESS
•<o-s,<oaJ_______________ ___
1
c^OOkJcxjU
0 - 4
. — 9
14
19
1
1
I
1
1
1
I
1
1
“1
40 - 49
1
.1
jj) - 59
1
. 1
1
60 tf.u
du?_u dHJ. j 1
-1
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.
i
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l
i
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i
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Z^UJui
1
1
1
no •
i do
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T
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T
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i ----------------- 1-
1
1
i
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i ----------------- 1 _
1
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i
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r
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ckratonvo
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ccutjo ckratonwu
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uij(J
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i no • i
cfo • ! zjjj 1
pry;
1
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■
■
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------------ 1------------- b-----------------
1
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1
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L
1
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1------------ 1--------------,--------------1
1
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)
1
1
1
1
1
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T
11
II’
1
1
1
1
1
A
1------------ 1--------------r___7
1
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1
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1
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i------------- 1--------------r-n
1
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1
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11
1
1
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!
i
PROFORMA
INCIDENCE OF SNAKE BITE AND DEATH CASES IN
BANGALORE URBAN DISTRICT
During the month of
Age
Group
OUTDOOR
M
F
T
M
M
INDOOR
F
T
M
M
DEATH
F
T
M
Remarks
0-4
5-9
10-14
15-19
20-19
30-39
40-49
50-59
60 & above
NOTE:
M : MALE
F:FEMALE
T: TOTAL
PROFORMA
INCIDENCE OFTHE RESHER ACCIDENTS REPORTED IN
BANGALORE URBAN DISTRICT
During the month of
Cases of thresher accident reported during the month
Name ol the
Hospitals in
the Districts
Amputation of:
°
Major reaspns of
accidents if any
reported by the patient
Signature
Remarks
MONTHLY REPORT OF SALT TESTING BY USINGS FIELD KITS
Report for the month :
Name of the PHC :
Iodine content of Iodised Salt in PPM.
0
7
15
30 and above
Houses :
Shops:
Total No. of Salt samples :
Signature of the
Field Worker
Signature of the
Medical Officer
i C '?'<
r cj
IdCI
W'bJ
|edn-uL
woJ oa e.afJ_ d jti o^pooodjo^r^^skp^^jrw
soJjoSjkto
57)0^,30
37) o ot> 5o_a o u^ajsoti a 5_apo_
cnjaiia_ao7)30odjyci0ja_t?oda^c=^ wpcLS^aoara NjpaNjp pooap ago
1) 199
?5e.
2) 300 3ot)3o3 o057)0odo godoo
n7)O3___ _______________ <Bontf
ojsj,
asraFO:
_______________________ _________________________ 37)007)^50
_____________________________ _____ adK
3) wOe.& aoTiac ova^a aoTioonv mjd no^:
■
4) wOe_c<x)d auad3 aocidOrw aao:
4-1
tjo3o7)e.a^ ooaau^a wa>us5 aoadontf
4-2
yo3o7)?_Btf troTjao^a ova^ auDdOrttf ^ci)t37)a7)Uj ooaj^ :
4-3
15 a-o’>-so-nos gado wodoTJca^ wozfacsja c/ua^Fcs
aorjaoritf nosJ^ :
4-4
15 a-a-ao. no5 sadj eK)5Jae.arf wogacioa oua^a
aoTjeJOrW aoaJs : 3?.3^7)37)30 -
4-5
is a-a-so- ao3o_,
:
a>?joa u>odo7)e.aFf
<3O5a0oa (Aia^a aorjciOritf .75021.3:
4-6
15 a-a-ao» aoso^
cSdju wdoatfiFf woaaood
(A)auF3 SODdOrW de.2)07)37) do 3021^ i
OFtDOS 5
23^^2320:1998 :
Neb:
300
?!■
;• .
'
.
KARUNA TRUST
RURAL IILAI.TII PROJECT
?' .
YELANDUR
Progress Report for the month of
Numa of the VHRW .......................................
Y
Nd,,l° of the
During
mon th
Household Survey
the
Cumulative
population
No.of Enumeration
No.of Examination
...X- LEPRQSYx
No.of cases Reg from
beginning
----- Ho.Of L-ases newly ddtb'CCucT"
■Nty.-o-f—cases'-on—treatmen t
No. o f~f (jTKpssd-cases
^FrorofTreathtlon-casas" . .
. fl.of defaulter cases
j .
No.of total RFT cases
!. , No.of.RFT; during the monTfT
j.,:
No.of.'RFT Follw up done
’ ■
No.of total RFC"cases
! i .Ho.of RFC during the* month
■
No.gf srnoar ■ taken dCJTTTTg
the month :
'
■g
No.of case's reg. from
Me ginning
1: /
3
Ho.of newly detected case
*dgring the month
Ho.of cases on treatment
No.of defaulters
Ho.of defaulters restarted
' KO.of sputum collected m
field.
•No.of sputum collected in
clinic
■ Ho.of sputum positive
No.of X-ray done
1
Total
—EXTfT'
OK.-
w
V|4J'
r^-
.u EPILLP5.Y;
.' No.of cades rug. from
/■I beginning .
No.of newly detected during
the month
!'•
•4----------- --------------- ------- ---------------------- ------------------------
p
No.of cases on treatment
!•
Oruo Del iverY £.0in.tU.
• J;
No.of cases . to be attended
—
■ 'rr--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
;
I
!;
No.of cases actual attended
4
..
...... .. -r
—
No.of cases to be attended
■
No.of cases actual attended
li •
no.of GTCs ca‘seS~not~on......................
[■
t ;|
treatment
No.of defaulter cases
• !
No.of de faultier’ started
I!'
i!
|i ■ .
:
..................
’
•_
retreatement
,
V|
tOlM tMi
.
oVs ”'"Tlb-l /
#
I ■ -Total No.of cases reg.from
' • beginning
i| *
:ij
f
..........................
4
\e
no.of cases newly detected
dur inp the .month
No.of cases on treatment
i
1
i
i
|
\
i
i
.
_____ J
1
1
1
restarted
i
1
1
Ho.of cases'defaulters
—
£
•
j ■
.
1
’( ' .Ho.of cases defaulters
•M
i
cjmlbgli.
Z'
>■
./■
j,’
:'
Total No.of cases Rag,.
•
X
. ..yf!" • . No.of cataract detected
/•'■j' - .-during the month
-..Total No.Of cataract
’ ■ • operation during the month
if
j
. |i . • •
■;’
-';
“
-i ‘—:—------ -
'
r“
. Still how many casus ponding
for operation.
~———
T---------------------- ---
No.of Vit ,'A’ deficiency cases
•;
Ji ■
;i .
detected
■
-—-—————■———■
No.of Vit ‘A’ deficiency cases
treated
_
’ ji '
:-
,
‘ . p ‘
No.of eye problems treated
L. I- ■ ...........
during
the month
—
...................... ........... ............................... —
K-'T6, CANCER: ' .
'
■ I
'
i>.- •
■■■■ -Jf"■>'.?'’Totai
No.of cases Reg.
No. of cases du tec ted
-W ; ■" during the month
Tk • •• a ■'-------------------- —
---------------- - - - ^---------------------------------------------------•i!
" No.of cases referred for
, . |. ■ treatment.
'■
•
• P ■
'
—
'
-X-.---'
---------------------- ---------------------
No.of cases pap smear taken
i
’■ H~----^-T-;----------- --- --------------------- —----------------------------------- __________________
J’
No.of cases on treatment.
i< T~*—~~---wir-i-j---- .
»
.
7. DENTAL
•I J
HEALTH:
!
-:‘ No.pf cases registered
rrt
1,
•1
z. No.of cases treated during
• ... . tht? month
■’
—————.. ....... — ______
// 8. AIDS & STD: '
'-No.of awareness programme
".conducted .
-No.of cases detected during
V
i- ’
I'
L_____ ._Jd3.9_JI!°CLLh._____ __
. No.of cases treated
!
.
no.of cases
J
?>!(!■
reffered
.
.
?
H
' .
'■
A
■ s
asthma
/ /,' TTotal
Z
nqTq?
& arx (fur ullUdr«n ul'Uur b
No
. oMu~^t7ctu/during
f cases_.Lg.flA
. ..........
~rj-.......
........................................
ca»
the
month
____________________________
No. of cases-tTUtTCHd
Y
10, SCHOOL & ANGANWADI
'■
■
Total No. of school & An’ganwadi
in your panchayathi area.
j-
;
HEALTH:
j
---- ;—- ----- ■------------------------- ;-------------------------- i
■
• ,
No.of school & Anganwadi survey
and health education given during
• the month
i
i,_.”
i ■ ii.
' . .....................
’
Still how many pending
i
■
’'
diarrhea;
' • .
No.of awareness programme
conducted
r
No.of diarrhea cases detected
during the month
ji
hf
’L
;
'
No. of. cases treated with ORS pekts.
i
‘•.r 12. ANEMIA:
* .
/
i
.
K-T •
F He .
Total No.of cases registered
j.
;
No.of cases detected during the
month
•
»
No.of crises treated
'
: .
:• J,
j
\ ‘
'
13.’ WATER & SANITATION:
.
: . - -h ■
Total No.of toilet constructed
this year
-A
No.of-toilet constructed during
tha^nonth
■
Total'. No.of ’water Porewell
constructed this year
■'
Total No.of water borewell
constructed during tht? month
• - -----
K • I
/. (/ i
1) Nov; C;i :;0 s detected
\ -4 - •'» Q r.ut nn treatment-
■ it)
ii' ':■ '1'1
v. ■ >
LJ ! ■
A< •,
under treatment ;
■■ ■ iv) 4 ■ 1 .1 sired cured
:
• U Ji J. J_c.XLJ2_ 8 I 8:
1) Nov; C q £C 3 detected
:
.Jh <
11 ) >’ -'J cases put on treatment:
Ik'
.
. .
ill) Old Cases under treatment :
’iv)
:
Declared cured.
LPAJ1L -
i) No .of. Children given Vit, 'A'
i.U
■1-C.
Ol
' 4^
extract operation done
iii) .No, of other eye operations done
— < J..
Ng-; of Eye camps done
,v) . Sputom Examination
....... •
. ■
b r gin 7~ 14 12 94 /-
■ ■ —
'
Pc
t.,'
BASIC'MONTHLY
i AT I OH 01! T,id PROGRESS OF IbiPO rtf ANT •NATIONAL PROGRAM!’.?
— •*-*
— — •— . —II'L'W
•—
.« • — . ..........
........
ACilI .'Z/Ei'i.jii’l’G
i
FJ-HLY ",
I.
■;? ... A/pppA
;
z"
■a) —uLuqUo) :y
i
,» . . i
■ b-; ..7asec.tun.7_______________
i
1
1
;‘J. 11
C; 0..A. j*
1
1
- •
1
1
1
■
i
i
’ \
'4'/
................ V ')
. W.ro d h DI s t r i bu t e f ;j
VI. No. of O.P. Distributed
• ’’ll.
No. of M.T.P. Cone
’
"
•
i
i
i
i
i
i
i
i
i
1
• | . _. . . • •
i
i
.
/
»L
1
■
)
I
v) -T.T., -Booster
vi) Polio
_ ..
3rd dose____________
vii) I.F.A. Tabs.
(Mothers)
I .
' r
-7~T.— -*•*--/-----------
A ‘ '■
i
1
P. VivaX
T
il) P. Falclpai'in
ill) Others
iv) Total
v) R, T. Gi ve n
i
i
---------- ~____ _ ----------------- 1
i
i
----------------- 1
i
i
_______
1
1
1
y / . . 1• - . ‘
i
il dose
i
i
i■
i
____|-----— —-------- —
—
1
. •
1
’
'i 'I
.„L-----------------------------1
1
!
1
11 D.P.T. (Booster dosej
— - r .-- - -r ■■■
*"i i i 2 Jp_&JT 5 J _ J2 22 _ _ _ _____
i
i
i
i
i
___ i____________________ __________ i
i
i
i
i
i
i
Si ?
I. i) D.P.T. (3rd dose)
4
i
i
i
i
---I-V. -Oral Dills
o rem/12120-1/-
. •,
r
-III.- C.C.. Users
..... iv)
i
i
i
i
i
i
i
..
:
i
___ i________ _ _____ _—
- -IT,. L.-ll. .J),
..v,. No
:
l
‘
1------Darin : *. ’? e I P i.’ogi-'issivo 'lot.al !
i to the end i U’tliu i
.' „.!'• h
i
[
Month
i
1
"■"1
1
I
1
i
....
1
1
lIC 'MONTHLY INFORMATION OU T.i
OF .Ti'lPOrtTAlTT -NATIOiiAu PROGRAl
a-1
1 P i.-ogi’issivo Total !
i to thu uilil ortho i
i;ionth
i
I.
•a) —uLuqCqj :y
r
C.tohi.7
r
■ IT.. I.-IL. . D.
L
-I-V.. .G.ral Pills
-V.. No^.c.!'. Nirpdh Distributer';].
VI
No. of O.P. Distributed
’ll
No. of M.T.P, Done
1) D.P.T. (3rd dose)
ii
D.P.T. (Booster dosej
L
- J J _ £2.4L' _ _ —
i'1 i 2 _
"ivT'O.' 'll dose
--v)-?,T> -Booster
vi) Polio
3rd dose
vii) I.F.A. Tabs.
P. Vivax
11) P. Falcipari!i
ill) Others
iv) Tot til
v) R, T, Gi ve n
orgtA/i212'J-l/-
4
1
BY NO. OF LIVING CHILDREN
Discription
Vasectomy
Tubectomy
Laprascopic
Total
UD
Remarks
1
2
3
4
5
6
7
0
1
2
3
-
4
5 + Above
Total
EDUCATION OF WIFE
Illiterate
Literate
Primary passed
Middle Passed
S.S.L.C. Passed
Graduate and above
Others
Total
-
EDUCATION OF HUSBAND
Illiterate
Literate
Primary Passed
Middle Passed
S.S.L.C. Passed
Graduate and above
Others
Total
Place
Date
i......
Signature
Designation & Full Address
(With office Seal)
Annexure IV
SOCIO DEMOGRAPHIC PARTICULARS OF FAMILY WELFARE ACCEPTERS REPORT PERTAINING,TO
199
(PHC/U.F.WC.).......... TALUK.......... FOR THE QUARTER ENDING
Name
Vasectomy
Tubectomy
Lapara scopic
(MYSORE DISTRICT)
Total
IUD
Remarks
BY RELIGION
1
2
3
4
(2+3+4)25 5
6
7
Hindu
Muslims
Christians
Sikhs
Others
Not Stated
Not Available
Total
BY CASTE
Schedule Caste
Schedule Tribes
Other Castes
N.S. (Not Stated)
(Not Available)
Total
BY AGE OF WIFE
less than 15 Years
15- 19
20-24
25-29
30-34
35-39
40-44
45 + above
Total
-
KARNATAKA HEALTH SYSTEMS DEVELOPMENT PROJECT
i SCHEME: ANNUAL HE-.LTH CHECK-UP FOR SC/ST POPULATION 1997-98
REPORT FOR THE MONTH OF
TO be COMPLETED-^ Y .THE
LiriA-MEplQ^L-0FFICER“A“iD~SUBMITfED“T
• before 7th of every month
Taluka ;
District:
NUMBER_O.F BENEFICIARIES _
-DETAILS _0F CAMPS HEuD.DURINS THE MOaiTd ..
Examined during the month
Treated
PHC
Sub Centres
No.of ’Villages
YELLOW
1.
2.
3.
4.
5.
6.
7.
3.
9.
10.
11.
12.
13.
.?T
- ---Grand
AdultgChildren-Tot? Adult children idtalTotal
M
F M
F
F
F
Referred
_SC _SC Total SC_ST Total
Number of patients with common Diseases as
Drugs used
^listed below
“No.
No
Name
1. Fever coses
12 Skin Diseases
lab .Aspirin
2 . Diarrhoea
Leprosy
" Paracetamol
3" Diclofenac
b)
4. Upper Respiratory
11
Ibuprofen
Pyodenna
Laboratory Tests Done
Others
d)
5. Pneumonias
" Cotrimoxazole
Type of Test No.of Tests
No.o
13. Pelvic Infla
" Mebendazole
Tuberculosi
s
6.
Conducted
mmatory Diseases
- __
(suspected)
"
Ferrous sulp
Cervicitis
Stool for Ova/cyst
Salpingitis
cap.Ampici1li n
7. Worm Infestations
Urine for Sugar
Endometri ti s
Cap. Tetracyclin
Urine for Albumin
(Clinical & Stool positive
14 Pre eclampsia
(<6gm %)
cases)
Haemoglobin (%)
Gentamycin eye drops
15 Sexually TransBlood for MP
8. Anaemias
Sofra.nycin skin oint
(Hb%6gm
&
below)
Blood Grouping
soframycin
skin oint
16. High Blood
9. Eyes
Vitamin A drops
Major Constraints experienced in
a) Vitamin 'A' Deficiency 17.
Others
-Conducting the camps
(night
blindness,
present
in
Urine)
1.
18 Goitre
Betots Spots)
2,
Eye
Infection
b)
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Yei’nw Card
Report for the nxxjrh of
£
-J
To be. . -aplctcd by the Tak.ka Medical Oflicer and submitted to the. District Health & Fiumly Welfare Officer before 7th of every month.
■■
_____ ;___
_ --------------- ■ ■•
.
Refer ed _ . £
Grind
Total
SC
ST
Disease
L---- ■ £
1: Fever Cases
. . --------
....
..
! ;
:
. •....... ........... .
•
r-
e
■
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Lxbomtmy Tes.h does
No. oL
posh- f. tests
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—’
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• • • 5£*-7
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a 5
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Tab. Ibuprofen
...Zec/z....
— ,
J______L . < „ -
b) Salpingitis
Tab. Ferrous snip
S. /Knacrrj.15 (lib*. 6grn A txkr-v) .
c) EiKSomctritis
Cap. AntpicJlra
—
Cap. Tetracycline
—
r
Gcntrnycia cy • drops.
—
1 1
-.
1
-
14. Pre EcLsmpsia
15. Seruxa! trrrrsmri'.d discac-.’ - •
A 6.
Hugh Blood Press cm
—
Vitamin A dreys
18. Gott-
Otberj
19. Fbarosis
20. Lwa=ncss from any caurr .
—
d) Rcuactory errors''
•—
.
’.
-
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i dis-■
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Sofrarn/crn eye oiut
-
m Untc)
<r -
Sofnmyctn stir. orrX
<T7. Diibcto (Sugar present
— .'.
a) Discharge
Tab. Furozolidine
13. Pelvic Inflammatory Disc-i.-.a
c) Catanci
■ - -T;-
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’:
•
•
'
a r
;
i
,-b) Scabies
Tab. Paracetamol
(Clinical A, Stool Positive Cases)
lO.Easr * ..
'S
”
i
IT
a) Leprosy
H-.+->•'- *—
Tab-NtitrrJ^-Je
I l.'Dcsrfil c.
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rf2L Skm Diseases
'-.... . -4' — -
“ Qiia.-.Uy
Name
'.
:r -
Majvr coastrfante erp:rj
Dngj Used
No,
Disease
I.
Blood grouping
—
a) Cervicitis
b) Eye Infection
" "" -^.5’ ---------
T'
<?
IS’
bHndv.ess, BctoG Spots) •
(< Spa %)
Db.
Tottl
Worm Infestations
a) Vitxrrrii 'A' DcfTiciency (bigirt
• •
sr
6.. Tubeniulc.ris (Suspected)
9. Eyes.
— •
Ake1
Bkod fci-MP....... -.*-•• r -•
F
SC
d) CXicn
i
•• —
"
Haemorlcbin (%)
M
*<) Pyoderma
M
Stool foe Ova.'Cyst
/-7
Total
—
_—
■
i
Ura.' for albumin
—
5. Pncunot::.-.?
j
’
4-^
Upper Respiratory Infection
•
’
Type of lest
...4^
.
3. Gastro-enteritis
’
F
(4
No. ■
2^ Diarrixea
• ;
<• ’
.M
III
F
1 2-
....................... .. .......... Number of padeoct with Cooinwn DBensei is listed f>6ew
5
...... i
. . . - _. _
M
F
4-4
H< •
1,\
■ r
......r_i
Total
'
-
• 1
...
•:
____Adult
1
1
_J_
Tctil
r A
. d -
ST
.
i
____ Children
- i-.
;
!
Adult
>•
....
SC
-
’
-- -•
.
J • *!>.< .
..
Tt? . •’
. iyxl'l»
:
■■
1. •
■
r "
r
Treated
......
■ •
---------
.
.
...
-J
kv:t ■mhrd.G.
i
'■
■ !■■
J Examined during the month
• '
Vx of Villages
•
•
......
Number of
—
PHC
C HflKIOKfiTZ?
r — r-
Dusri
— ■
- i
Details of camps he’d durktg the month—---:----- ;r ■
T1
71
:
............. -
-
-2-: t.r
.
....
’■
!
~n
MONTHLY STATEMENT SHOWING THE INSTITUTIONAL CASES AND
DEATHS DUE TO COMMUNICABLE DISEASES
Name of the District: Bangalore Urban District
Month
REPORTED CASES AND DEATHS DUE TO COMMUNICABLE DISEASES
Patients treated
SI.
No.
Name ol the Diseases
OPD.
1.
Acute Diarrhoeal diseases
(including Gastro Enteritis and Cholera)
2.
Dipthcria (045)
3.
Acute Poliomyelitis (045)
4.
Tetanus - other than Nconatala (037)
o.
Neonatal Tetanus (771.3)
6.
Whooping cough (033)
1PD.
Total
Measles (055)
Acute Respiratory infection
including influenza and
excluding Phcumonia (460-466) (487)
9.
Pneumonia (480-486)
10.
Enteric Fever (002)
11.
Viral Hepatitis (070)
12.
Japanese Encephalitis (062.0)
13.
•
Meningococcal Meningitis (036.0)
(320.0)
14.
Rabies (071)
15.
Syphilis (090-097)
•
Gonococcal Infection (098)
17.
Pulumonary Tuberculosis (0.11)
18.
All other Diseases ’treated in institutions
excluding above mentioned diseases
(’including communicable and
non communicable diseases)
TOTAL
Signature
Death in
(IPD only)
MONTTjl^ STATEMENT SHOWING THE INST1TUT1QNALCASES AND
^DEATHS DUE TO COMMUNICABLE DISEASES
*0.,.^’
^-Na^oilh^Dlstric) ^Bangalore Urban District
Month..
/* /
■■ • <
REPQlVpiCl) CASES AND DEATHS DUE TO (.’OMM UN ICABLE.DISEASES
Patients healed
' SI.
No.
1.
Death In
nly)
(IP
Name of the Diseases
OPD.
Acute Diarrhoeal diseases
(including Gastro Enteritis and Cholera)
2.
Dipthcrla (045)
3.
Acute Poliomyelitis (045)
4.
Tetanus - oilier than Neonatala (037)
5.
Neonatal Tetanus (771.3)
6.
Whooping cough (033)
7.
Measles (055)
Acute Respiratory inlection
including influenza and
excluding Phcumonia (460-466) (487)
9.
Pneumonia (480-486)
* ' 10.
Enteric Fever (002)
11.
Viral Hepatitis (070)
12.
Japanese Encephalitis (062.0)
13.
Meningococcal Meningitis (03(^j^_
(320.0) ~
£
14.
Rabies (071)
15.
Syphilis (090-097) \
IPD.
>4
9)
Gonococcal Infection (098)
17.
Pulumonary Tuberculosis (Oil)
18.
All other Diseases * treated in institutions
excluding above mentioned diseases
(•including communicable and
non communicable diseases)
TOTAL
No. CM D/1 IS/
/05-96
2^
.1#
g, q pi I ice ol lhe Disl. I Icallh 4 FW Olliccr
No.4, Sirur Park Road, Seshadripuram,
Bangalore 56(1 020 Dated :
Copy submitted for kiq£jiij‘oniiitlioii to :
1.
2.
3.
4.
The Deputy Director, Communicable Diseases Investigation Cum Tiaining (‘enlte, Mandya.
The Assl. Director, Bill Section, DH & FWS, Bangalore.
The Divisional Joint Director of 11 & FW Services. Bangalore.
The Joint Director (CMD), Directorate oj’11 & FW Services, Bangalore.
S'Sigli;iluiXL
‘ VV_a^
mC'ER'
56000®
cfcfto
VICEB
SENIOR MEDK-- '
Ptimary V>'- ;n
KENCBR’_
ggngalors—
8
080-5514636
080-5514748
Fax: 080-5510224
Government of Karnataka
KARNATAKA HEALTH SYSTEMS DEVELOPMENT PROJECT
No.AD/CMD/53/99-2000
Additional Director (CMD)
State Surveillance Unit
K.H.S.D.P., E.D.Hospital Campus,
Old Madras Road,
BANGALORE-560 038.
Date:10.12.1999
To
Sub: Submitting of monthly reports on Communicable Diseases-reg.
With reference to the above subject, you are hereby directed to send the monthly reports
X '
in the prescribed Proforma (enclosed) every month to this office regularly without fail, within
the first week, so as to enable this office to compile a concise state report and submit to the
Secretary to Government, Health & Family Welfare Department, Government of Karnataka
for further needful action.
(Dr.S.R.BILGI)
Additional Director(CMD)
Sk-reports53-A
MONTHLY STATEMENT SHOWING INSTITUTIONAL CASES AND DEATHS DUE TO COMMUNICABLE DISEASES
Institution
District
1. Name of the State/UT
2.
Month/Year
3.
Total Number of existing Institutions for the month in the State/UT
4.
Total number of reporting institutions in the State/UT
5.
Total Number of Defaulting institutions for the month in the State/UT
6.
Reported cases and Deaths due to Communicable Diseases
M
No.
b1
Patient treated
OPD
Name of Diseases
SI.
F
C
M
IPD
F
Deaths
(IPD only)
Total
C
M
F
Total
C
Acute Diarrhoeal Diseases
(including Gastro Enteritis & Cholera)
2
Diptheria
3
Acute Poliomyelitis
4
Tetanus other than Neonatal Tetanus
5
Neonatal Tetanus
6
Whooping Cough
7
Measles
8
Acute Respiratory infection
(including Influenza & excluding pneumonia
9
<1
Pneumonia
Enteric Fever
Viral Hepatitis
-
12 Japanese Encephalitis
13 Meningococcal Meningitis
14 Rabies
15 Syphilis
16 Gonococcal Infection
17 Pulmonary TB
18 All other Diseases treated in institutions
excluding above mentioned diseases
Total
* Please take care not to include simple dog bite cases.
Including communicable & non-communicable disease.
sk-A:\Profcrma.xls
(Seal and Signature)
PROFORMA
IN DOOR PATIENTS AND OUT DOOR PATIENTS TREATED DURING THE MONTH OF
1
Type of Institutions:
II
No. of Institutions
General Hospitals
PHC’s
PHU’s
Total
Male
Female
Children
Total
functioning
1
No. of Institutions re
ported during the month
(100% reporting should
be ensured)
ii
No. of defaulting institu
tions during the month
II
SANCTIONED BEDS:
1.
General Hospitals
ii.
Primary Health Centre
iii.
Primary Health Unit
Out Door Patients Treated
Period
Type of Institutions
1
2
During
General Hospitals
the
PHC's
Month
Old Cases
New Cases
M
F
C
T
M
F
C
3
4
5
6
7
8
9
M
F
C
T
M
F
C
3
4
5
6
7
8
9
T
10
PHU’s
Total
Commutative
General Hospitals
From.....
PHC’s
till the end PHU’s
of the month
Total
reporting
INDOOR PATIENTS
1
2
During
General Hospital
the
PHC’s
Month
{PHU’s
•
DEATHS AMONG INDOOR PATIENTS
T
10
Total
Commulative
Gen. Hospital
From.....
PHC’s
till the end PHU’s
of the month
reporting
Total
sk-AAProforma.xls
(Seal and Signature)
aAOn* O.v
Monthly Reporting format for ft; Mcalth Male
Name of the Sub- centre:
Nome of the Worker:
Month
Year
:-Annu<J: :■$<:< . Monthly. •:
:Service :
■ Service-:-: :.::h:-:<: Ac! iieyem.ent;:h::t:c:.
need < ■:$: heed
■Monthly:- :'■ Cumulative2
1
3
4
(4/1) 5
1. Health Clinics
i. No. of Health clinics attended with
ANM
2. Family planning Methods
,
i. No .Persona motivated for vasectomy
1 Ji. No.Pcrsons using Ccs
iii No. Vasectomy cases followed up
3. Corrmunicable disease
A Malaria:
i. No. of fever cases identified
i: No.rf blocd smew slid'''' sent t-'HlC
iii. No. of cases given presumptive
treatment
iv. No.of positive cases given radical
treatment
v. No. of high risk villages identified
— —
vi No of anti -mosquito activities
co-ordinated
t
1
•r- *!•«• • >-»-• ••
Annual
Monthly
Iteryice
•’.need:
■ 3<rvw>;
■ need'.::';:;:
1
2
tAdiicyximMii
Monthly3
Cumulative
4
L No. of suspected cmcb identified
and referred
;
I
—
----- _----
—
C. Leprosy:
L No.of suspected cases identified and
referred
•
ii. No. of suspected cases followed up
D. Epidemics
L No. of GE cases identified and
reported
ii. No. of cases of preliminary
treatment tjiven
iii. No. of cases referred
iv. No. of cases other epidemic
diseases referred (Filariasis, Malaria
*tc.)____
_____ _____
4. Environment sanitation
-------- ---------- .
L Number of drinking water sources
chlorinated
1
i
B. Tubcr''u!osis:
il No. ofTB canes followed up
(4/1) 5
. . ......
Annual
, ■ .Activity
Monthly
Service i .Service
need ■
need
1
2
•
: AcJucYcirtent
■
Monthly :■
3
Cumulative
4
perceiiiiige
(4/1) 5
5. School Health
i. No. of school health programmes
participated
ii. No. of school children examined and
treated
iii. No. of school children referred
iv. No. of school children immunized
v. No. of school health cards filled
6. Interaction with community
i. No. of meetings with village health
committees
. .
ii. No of meeting with your committees
iii. No. of mecttings with village leaders
.
_ .
.
iv. No. of meetings with PMPs
7.IEC
i. No. of Health Education
Programmes on environmental
sanitation conducted
-------------- —
ii. No. of group talks to males on
contraceptive methods
iii. No. of health talks to males on
reproductive health
STD/RTIs/Infertility)
8. Reporting and recording
i. Malaria reports
ii Other communicable diseases report
iii. School health reports
1__________
____________
Equipment and Facilities
SI.
No.
Item
Available
(Number)
Functioning
(Number)
i
i
---------- ___
1.
Ambulance
2.
'“B.'P. Apparatus
— ----------........—
3.
Weighing Machine
4.
Microscope & Lab Equipment etc.
5.
Autoclave
6.
Oxygen Cylinder
7.
MTP Suction Apparatus
8.
ILR
9.
Deep Freezer
10.
Cold Box -
11.
Refrigerator - -
12.
X-Ray Machine
13.
Laproscope -
14.-
Kit E - haparotomy set
15.
Kit F - Min haparatomy set
16.
Kit G - IUD insertion set
17.
Kit H- Vasectomy set
18.
Kit I - Normal delivery set
kig.
Kit J - Vacuum extraction set
20.
Kit K - Embryotomy set
21.
Kit L - Uterine evacuation set
22.
Kit M - Equipment for anaesthesia
23.
Kit N - Neonatal resucitation set
1
"t
.
.
|
J
\l-.- ? '• \’. ’1
|
-
|
t
1
i
1
!
|
id |
*J
col
J
9.
.1___ L
— 5
_ 1
a
"
I
-------- — •
24.
Kit O - Equipment and Reagents for blood tests
____________
25.
Kit P - Donor blood transfusion set
-
1
1J
1
ii
__ 3i
°l
III
1
-
-
j
■
(Form 4 contd.)
Staff Position
SI.
No.
Category of Staff
1.
Medical Officer.
2.
Specialist
a) Anaesthetist
b) Gynaecologist
c) Paediatrician
d) Pathologist
e) Dental Surgeon
3.
♦
Staff Nurses / Nurse Midwife
4.__
Pharmacist / Compounder
5.
Lab. Tech. / Lab Asstt.
6.
Radiographer
7.
Computer
8.
Driver
Sanctioned
(Number)
In position
(Number)
Vacant since
what date (Number)
-
- -
--
-
-
9
Paramedical Supervisors
Malarra'tnspector----------------------- BEL
------------- ------------------------- -—-—
—
—
PHN / LAV
- ---------------------- —
---- -—HA------------------------------------------—
■ ■
■------- —
■
-o.^ 9 Multipurpose worker
■---- —--
... V
Male
Female
Signature of D.M.O.
^pRUGS
MANAGEMENT
SYSTEM
Quarterly
Reporting
Format.
Name of the bub-Centre/Primary Health Centre/
General Hospital/ District Hospital.
Slo Names of
No. all xne drugs
in stock as
on 1st April
of the year.
1
2
Opening
balance
as an 1st
Aprilo
3
Stocks
not mov
ing since
2 months.
4
Stocks
rec eiv ed
(from all
sources.)
Co nsumpt ion Cummulative
April to
consumption
June/July to since 1st
Sept./Oct.to April.
December/Dec.
to liar ch. as
the case may
be.
6
5
7
Quantity exp
Closing
ing in anoth
balance
4 months.
at the
end of
( *)
the quarter.
8
NB ( *) Notwithstanding this report action should
be taken to seek replacement as per Rate
Contract condition.
SIGNATURE OF DISTRICT SURGEON/
ADMINISTRATIVE MEDICAL OFFICER.
To
Director of Health * F.W.Services,
bangalore.
Copy to Joint Director
Govt. Medical Stores,Bangalore.
9
Quarterly
MANAGEMENT
system
Reporting
Format.
Name of the Sub-Centre/Rrimary Health Centre/
General Hospital/ District Hospital.
Si. Names ef
He. all the drugs
in stack as
on 1st April
of the year.
1
2
Opening
■stocks
balance
not mov
as un ist ing since
April.
2 months.
3
4
Stocks
received
from all
sources.
Consumpt ion Cumulative
April to
consumption
June/July to since 1st
Sept./Oct.to April.
Decembar/Dec.
to March,as
the case may
be.
5
6
7
Quantity expir
Closing
balance
ing in another
at the
4 months.
end of
■ ■■
the quarter.
8
NB ( *) Notwithstanding this report action should
.
be taken to seek replacement aS per Rate
Contract condition.
To
SIGNATURE OF DISTRICT SURGEON/
ADMINISTRATIVE MEDICAL OFFICER.
Director of Health & F.w.Services,
■Hangalore.
Copy to Joint Director G&vt. Medical Stores,Bangalore.
9
Surveillance system flow chart
F
E
E
D
B
A
C
K
&
D
J
S
s
E
M
E
N
A
T
I
O
18
Epidemiological Surveillance of Communicable Diseases
and Health Management Information Systems
Epidemiological surveillance is one of the important activities in the Health care
Delivery Services. In the KHSDP State is required to establish and effective surveillance
system which aims at describing health events over time in a simple flexible, acceptable
sensitive and accurate manner. The state has already initiated to collect data from various
reporting units ii) Strengthen the organisational structure at the district and state level .iii)
Strengthen the capacity and capability of district health administrators to analyse and the
interpret data iv) Enhance the capacity of the district health administrators to provide rapid
relief measures and to the problems of communicable diseases.
Existing Situation:
The major communicable diseases prevalent in the State are Japanese- Encephalitis,
Kyasanur Forest Disease, Infective Hepatitis, Polio Myelitis, Cholera, Gasrro-enteritis,
Plague, Typhoid, Tuberculosis Malaria and Filaria. The Epidemiological Data in respect of
Seven major communicable diseases in the State is given in Table below:
Disease
1995
1997
1996
1998
Attack
Death
Attack
Death
Attack
Death
Attack
1. J.E
329
102
127
17
31
2
97
12
2. K.F.D
174
03
140
03
75
04
47
01
□ .Cholera
532
08
657
06
741
10
4.Gastro
18645
396
22983
377
23665
306
5. Plague
72
-
93
03
-
-
6,Tuberculosis
83244
-
81785
-
79984
-
69422
NA
7. Malaria
2S5S30
32
219198
13
131450
7
107910
3
Death
02
26881
501
enteritis
-
State surveillance unit:
State surveillance unit has been established in the campus of epidemic diseases
hospital. The building has been constructed and occupied . The Additional Director CMD
and the skeletal staff attached to the state surveillance unit are in position. This unit is a
nodal office tor the activities connected with disease and epidemiological surveillance in the
entire state. The Joint Directors of malaria and filaria, leprosy and tuberculosis are
made reportable to the Director of Health and Family welfare Services to the Additional
director (C.MD). Earlier the above Joint Directors were directly reporting to the Director of
Health and Family Welfare Services.
There is at present a communicable diseases investigation and training centre headed
by a Deputy Director Working at Mandya which was grossly under utilized. He has under
him the following supporting staff.
1. Assistant Malaria Officer
2. Epidemiologist
3.
Statistical Officer
4.
Senior Entomologist
5.
Asst. Entomologist
6.
Entomological Assistants (2 Posts)
7.
Bacteriologist
8.
First Division Assistant
9.
Second Division Assistant
10.
Typist
11.
Senior Lab Technician
12.
Junior Lab Technicianfl 0 post)
13.
Driver
14.
Insect Collectors (6 Posts)
15.
Group D (8 posts)
In the steering committee meeting held on 21/04/1999 it was decided to transfer the unit to
State Surveillance unit which is now located at the campus of ED Hospital Bangalore. This
unit would function as state surveillance unit and also function as a district surveillance unit
Bangalore urban and rural Districts.
The functions of state surveillance unit are as follows
Evolve Strategies for Surveillance
»
o
Set up procedures for collection, analysis and reporting of morbidity' and mortality
data
Monitor the functioning of the District Surveillance Units.
•
Co-ordinate with other related Departments at the State level, Indian Medical
Association, Programme Officers, Voluntary Organisations, etc..
0
Conduct surveys compile morbidity and mortality data, by disease, for planning
and working out priorities and strategies.
«
Evaluate the effectiveness of interventions instituted to control epidemics.
o
Carry' out research studies and suggest innovative and the effective methods of
intervention.
Constitution of Co-ordination Committees for Communicable Diseases :
fhe activities shown above do not include the sentinel surveillance under taken by
NACO funded AIDS prevention and control programme. A State level co-ordination
committee is set-up to review and monitor the disease surveillance activities. A co-ordination
committee is set up at the state level by establishing a high level committee under the
Chairmanship of Chief Secretary to Govt.. This above committee would meet as often as
necessary atleast once in a quarter to take appropriate action in matters relating to
communicable disease and for instituting Preventive and curative measures. Similar
committees are also proposed at the District level and Taluk level for eliciting co-ordination
in the control of communicable disease. The proposed composition of the District and Taluk
level committees are as follows.
SI. No
District Level Committee
I
Deputy Commissioner Chairman
2.
Chief Executive Officers ZP Member
District surgeon Member
3.
District Health and Family Welfare
Officers Member
Executive Engineer ZP Member
Executive Engineer PWD
District Surveillance Officer Member
Secretary
4.
5.
6.
Taluk Level Committee
Chief Executive Officer (Taluk
Panchayath) Chairman
Tahasildar Members
Medical Officers of the Primary
Health Centres / Community Health
Centres Members
Chief Executive Officer of Town
Municipal Panchayath- Member
Taluk Medical Officer Member
Secretary
Taluk Level:
A basic Surveillance system exists at the Primary Health Centre level. The
Reporting system is already there at the level of field workers. The reporting systems is very
simple. However the inadequacies recently became evident during recent out breaks of
plague' in Gujarath and Maharastra. There is no surveillance Mechanism at the secondary
level and in the urban areas. Though there is man power at the primary level it is not
properly integrated into the State surveillance system. It is felt that there is a need to give
responsibility of monitoring the working of the system at the primary level to the proposed
Taluka Medical Officer. In view of the importance of this item of work, it is decided that one
person belonging to the clerical establishment in the Taluka level hospital should exclusively
collect , monitor and report surveillance data, on a full time basis. This official will have to
be trained suitably .
The Taluk Medical Officer will also provide orientation to other grass-root
functionaries, such as Anganwadi workers, school teachers, Gram Panchayath Members etc.,
who will become '■intormers’ under system.
District Surveillance unit:
1 here are Eighteen District Health Laboratories which are now redesignated as
district surveillance units. The medical officers working in district health laboratories are
redesignated as district surveillance officers. The functions of the district surveillance units
are as follows:-
0 Act as the nodal surveillance unit at the district level and provide the missing link
between the primary and secondary level sub-systems.
® Provide early warning of outbreak of epidemics of all the major communicable
diseases through continuous monitoring of mobility and mortality trends in the
district.
o Monitor and send Periodical Reports on Epidemiological Situation to the State
level and to communicate feed-back to the primary Health centres / Community
Health Centre and Taluk Medical Officers.
° Co-ordinate with other related Departments( Fisheries, Irrigation, Agriculture, Rural
Development ) and local bodies such as Zilla Panchayaths and other Organisations
like IMA in taking prompt action against the Epidemics.
The Following follow-up Actions are Initiated
Issues
Action Taken
1.
Shining
of
Communicable
Disease
Investigation and Training Centre at Mandya,
along with its 38 staff to Bangalore and attach to
the
Additional
Director
(CMD)
State
Communicable Disease Surveillance Unit, and to
function as District Surveillance Unit for
Bangalore Urban and Rural Districts.
2. Up-gradation of existing 18 District Health
Laboratories
and
re-naming as
District
Surveillance Unit.
New building is constructed and occupied by
the State surveillance unit.
The steering
committee on 21/04/99 has approved
for
shifting of CD! and TC from Mandya to
Bangalore in the meeting held on 21SI April
1999.Orders are issued in this regard.
3.
4.
Recruitment of the following staffs:
a) Micro Biologists
IS
b) Asst. Entomologists
IS
c) Drivers
IS
Orders are issued to redesignate District units
accordingly..
(a)The new cadre and recruitment rules have
been finalised.
(b)Recruitment formalities are completed .
Draft list of selected candidate is Published for
inviting objections if any.
The selected
candidate would be posted shortly.
c) Recruited and posted.
Re- Deployment the following staffs from
the Health Department to 18 District
Communicable Disease Surveillance Units.
7. Providing mobility to District Surveillance
Units
8.Formation of Intersectoral Co-ordination
committees
a) State Level
b) District Level
c) Taluk Level
9. Training programme of various categories of
staff in 18 districts.
Has been done. Details are in annexures.
Jeeps have been provided.
a) Constituted
b) Being Constituted
c) Being Constituted
Completed on
a) Sensitisation Work shop to District Health
and Family welfare Officers , District
Surgeon and District Surveillance officers
of Bangalore Division on 22/10/98
b) Six days Training to the Staff of Districts
Surveillance Units in two batches :23/11/1998 to 28/11/1998
22/03/1999 to 27/03/1999
10. Repairs and additions to the District
Laboratory Buildings.
11. Reporting Format's
Current status
Annexure
Designed
12. Manual on Disease Surveillance
13. Initiate nosocomial infection
programme
Prepared and distributed.
Done.
control
is
shown
separately
in
Surveillance system flow chart
lA
18
Iki p-l'‘ p
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