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 Format I - List of Health Staff under Hydroxy -Chloroquine Prophylaxis
Name of the HUD: Name of the PHC: Date:
Consumption details
if any
If anyone
Adverse
reported
events
COVID-19
Name of the reported
S.No Designation Mobile Number symptoms,
Heath Staff Day 1 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 (Yes or
(Yes or No).
No). If yes
If yes , Give
, Give
details
details

Note: To be maintained at the level of PHC and Block Concerned

 Format II - List of Asymptomatic Household Contacts of Positive cases under Hydroxy -Chloroquine Prophylaxis

Name of the HUD: Name of the PHC: Date:

Consumption details
If anyone
if any Adverse
Name of the reported COVID-
events
Asymptomatic 19 symptoms,
S.No Address Mobile number reported, (Yes
Household Day 1 Week 1 Week 2 Week 3 (Yes or No). If
or No) If yes ,
Contacts yes , Give
Give details
details

Note: To be maintained at the level of PHC and Block Concerned

 Format III - Stock Position and Utilisation of Hydroxy -Chloroquine Tablet from PHC to DDHS office

Name of the Block: Name of the PHC: Date:

Health Staff Frontline worker Household contacts Total

Opening Closing
Utilized
Balance Balance
As on date Upto date As on date Upto date As on date Upto date As on date Upto date

Signature of the Medical Officer

 Format IV - Utilisation of Hydroxy-Chloroquine Tablet report from DDHS to DPH &PM

Name of the HUD: Date:

Name of Household
the Health Staff Frontline worker Total
S.N contacts Opening Closing
Primary Utilized
o Balance Balance
Health As on date Upto date As on date Upto date As on date Upto date As on date Upto date
Centre

Signature of the Deputy Director of Health Services