COMBINED REPORT, REQUISITION, ISSUE AND RECEIPT FORM (CRRIRF) - Antiretroviral, Cotrim and RTKs (PMTCT)

Facility Name: ORISUMBARE PHC

Reporting Period Start:
1/3/1016
Facility Code:_________________________________

Reporting Period End:

State: LAGOS

S/No

29/04/2016

Date Prepared:

Drugs

Basic Unit

5/5/2016

Quantity Received Quantity Dispensed

during Reporting
during the
Period
Reporting period

Ending Balance
(Physical Count)

Remarks

ARV FOR PREGNANT MOTHERS

1

AZT/3TC/NVP (300/150/200 mg)

60 tabs

TDF/3TC/EFV (300/300/600 mg)

30 tabs

3
4
5
ARV FOR EXPOSED BABIES
7

Nevirapine NVP 50mg

30 tabs

Nevirapine NVP 50mg/5mL

100mL

OPPORTUNISTIC INFECTIONS DRUGS

9

Co-trimoxazole 100ml

btls

10

Co-trimoxazole 120mg

tabs

11

Co-trimoxazole 960mg

tabs

50

50 BORROWED FROM AKOWONJO

HIV Test Kits

12

Determine

1 test

4500

4577

13

Unigold

1 test

60

32

47

14

Stat-Pak

1 test

15

Double-Check Gold

1 test

16

DBS

REQUIRES 3 DBS KITS

LABORATORY REAGENTS
17
18
19
Comments:
1. Please provide details (expiry dates & quantities) of any commodity that has expired or will expire in three (3) months time
2. Any other information
S/No

Description

Report Prepared by: (Full Name)

Quantity

ADEBAYO J

Expiry date

Phone contact

Report Approved by: (Full Name)

Phone contact

Requisition Approved by: (Full Name)

Phone contact

Drugs Issued by: (Full Name)

Phone contact

Drugs received by: (Full Name)

Phone contact

08100806375

PATIENT PER REGIMEN Form

NAME : ORISUNMBARE PHC
Reporting period
1
2
3

1/3/2016 - 29/4/2016

Current number of patients (Adults) on ART/PMTCT

HIV-exposed infants
Number of persons that received PEP in the period
Total
Regimen

1
2

Adult First Line (ART/PMTCT)

Tenofovir/Lamivudine/Efavirenz (300/300/600mg)
Zidovudine/Lamivudine/Nevirapine (300/150/200mg)
Total Adult First Line (ART/PMTCT)

1
2

HIV-exposed infant
Nevirapine Suspension 10mg/ml
cotrim/250mg
Post Exposure Prophylaxis (PEP)

1
2
Total Post Exposure Prophylaxis (PEP)

Record compiled by: (Full Name)_ADEBAYO J___________

Telephone________
Record
ADEBAYO J

9/4/2016
3
2
0
5
Current No. of patients

3
0
3

1
1

0
0
0

8100806375