REP Form 1 HC Work Plan (Q1,Q2)FORM 1: HEALTH CENTER WORK PLAN
FOR REACHING EVERY PUROK EVERY QUARTER
Name of RHU/BHS: ________________________________Date of
Completion: _____________________
Name of Midwife: _______________________Name of BHW:
__________________________
Barangay NamePurok NameResult of previous card checks
(HR/LR/ND*)QUARTER 1QUARTER 2Date for master listingDates for catch
upDate for next door to door card checkResults of latest card check
(HR,LR, ND)Date for master listingDates for catch upDate for next
door to door card checkResults of latest card check (HR,LR,
ND)JanFebMarAprMayJun
REP Form 1 HC Work Plan (Q3,Q4)FORM 1: HEALTH CENTER WORK PLAN
FOR REACHING EVERY PUROK EVERY QUARTER
Name of RHU/BHS: ________________________________Date of
Completion: _____________________
Name of Midwife: _______________________Name of BHW:
__________________________
Barangay NamePurok NameResult of previous card checks
(HR/LR/ND*)QUARTER 3QUARTER 4Date for master listingDates for catch
upDate for next door to door card checkResults of latest card check
(HR,LR, ND)Date for master listingDates for catch upDate for next
door to door card checkResults of latest card check (HR,LR,
ND)JulAugSepOctNovDec
REP Form2 Masterlist of childrnForm 2: MASTERLIST OF CHILDREN
(0-23 MONTHS OLD)
Name of RHU/BHS:
____________________________________________Name of Midwife:
_____________________________Name of Barangay:
_____________________________________________Name of BHW:
________________________________Name of Purok:
________________________________________________Date of Completion:
____________________________
Name of ChildAgeBirthdayName of MotherDetailed address in Purok
including landmarksPlace if vaccine has been givenPlace if mother
recall TT doses RemarksBCGHepB BDPenta 1 Penta 2Penta 3OPV 1OPV
2OPV 3AMVMMRTT1TT2TT3TT4TT5
REP Form 4 Quarterly card checkForm 4: QUARTERLY CARD CHECK IN
HIGH RISK PUROK TO MEASURE RISK STATUS IN ONE PUROK Method: DOOR TO
DOOR VISITS FOR CHILDREN AGED 12 TO 23 MONTHS
BHS Name: ____________________ Barangay Name:
_________________________ Date: __________
Purok Name: _______________________ Health Worker Name:
_______________________
Door No.Immunity Gap Card Check (12 to 23 months)No. of Children
with No Card (Write name of child with zero dose and no card on the
back of this form and check in TCL)No. of Children aged between
12-23 monthsNo. of children with cardNo. of Completely ImmunizedNo.
of Partially ImmunizedNo. with zero dose (3 doses of Penta plus
MCV1 and MCV2)(Any one dose of Penta or MCV missed) (Card shows no
doses received)1234567891011121314151617181920
Form 5 Consolidated monitoringFORM 5: CONSOLIDATED MONITORING OF
QUARTERLY CARD CHECKING IN HIGH RISK PUROKS
Health Center Name: _________________________ Barangay Name:
______________________________ Date: ______________
Name of High Risk PurokDate of Card CheckResults of Card
ChecksResult of Catch UPNo. of Children CheckedNo. of Children with
CardNo. of Completely ImmunizedNo. of Partially ImmunizedNo. with
zero dose no. with No Card% Completely Immunized Decision on High
or Low Risk % Children without CardsDecision on High or Low
RiskDate Catch Up Done for High Risk PurokNo. Penta Dose GivenNo.
MCV Given
% of Completely Immunized - In puroks where most children have
cards:Number of children with complete immunization X 100Total
number of children with cardsHigh Risk Purok: