FORM 2: CITY/MUNICIPALITY LEVEL MONITORING AND ASSESSMENT OF READINESS FOR OUTBREAK RESPONSE IMMUNIZATION

City / Muncipality : ________________________ Target Population (0-59 months): ____________

LGU zoning (ECQ/MECQ/GCQ/New Normal) _________________ Effective Dates of COVID-19 zoning: ________________ Strategy (H2H/Fixed Posts/Mixed): _________________
Name of Monitor: _____________________ Agency: ___________ Respondent (Position): ____________________ Date of Visit/Assessment: ___________

6 wks 4 wks 2 wks 1 wk

If not
accomplished
Area Critical activities plan achieved (Y/N) Action required
describe
Mark "X" planned activity deadline. deficiency

1. Budgeted microplans developed for

resource mobilization purposes

2. Campaign budget allocation done at

city/municipal level

3. Political commitment of the Local Chief

Executives

4. Discussions with LGU COVID-19 Task Force

to support campaign and mobilise resources

5. Local Polio Emergency Operations Center

established and meeting daily
PLANNING, COORDINATION & FINANCING

6. Local Polio Incident Management Team

(Emergency Operations Center) established
with clearly defined roles:
a. Technical including monitoring (EPI
Manager)
b. Vaccine, Cold Chain & Logistics (Logistics)

c. Advocacy, Social Mobilization &

Communication/ Media Relations (HEPO)

d. Risk Management/AEFI/AFP/COVID-19
Surveillance (C/MESU)
 PLANNING, COOR

e. Patient pathway and referral system (for

COVID-19 suspects)

7. Adequate number of human resources for

campaign (specify # of vaccination teams)

8. Funds available to the city/municipal level

for operational costs (e.g., transport)
9. Microplans available at all RHUs/ health
centers

10. OPV guidelines, supervisory checklists,

tally sheets, summary report forms, AEFI
forms, etc. printed and distributed

11. Plan and budget for campaign

VACCINES, COLD CHAIN AND MONITORING/
SUPERVISION

supervision, monitoring, and RCA available

12. Pre-campaign monitoring visits to

RHU/Health Center to assess preparedness
planned and budgeted
13. A budgeted logistics plan developed
14. Received required vaccines, safety boxes,
PPE and additional commodities
LOGISTICS

16. Cold chain assessment completed and

action taken
16.Immunization Waste management plan
available
17. Bundled vaccine and other ancillary
supplies distributed to all RHU/HCs

18. A budgeted plan for advocacy, social

mobilization and communication developed
SOCIAL MOBILIZATION AND

19. Advocacy & community engagement

COMMUNICATION

meetings held with partners and

stakeholders - e.g., other departments
(DSWD, DILG), church groups, NGOs,
professional/medical societies, civil society
groups (e.g., Red Cross, Rotary, Lions) and
others
SOCIAL MOBILIZA
COMMUNIC

20. Advocacy, social mobilization and

communication materials developed and
distributed with special focus on
immunization during covid
Total score: No. items with "Yes" 0% General Remarks:
Circle time of assessment: 6w 4w 2w 1w
Is the regional level on track to conduct the ORI?
 Person
Deadline Remarks
Responsible
CAMPAIGN READINESS ASSESMENT AT HEALTH CENTER LEVEL

Name of Health Center: ____CHO MATI____ Strategy (H2H/Fixed Posts/Mixed): _________MIXED_____

Name of Respondent / Position: _____MARIO P. LUTOG JR. ,RN/ NIP COORDINATOR Date of Visit: ______________
Microplan
All puroks/areas are included in the barangay microplan
List of all transit points, markets, congregation points, religious gathering places, day care centers, evacuation centers, isolation fa
catchment area available
Plan to reach high risk populations included: high risk areas identified, vaccination strategy identified, details about any special arr
available, areas are included in the monitoring and supervision plan
Daily activity plans for the teams are available: indicating assigned areas, strategy used, estimated target population
Special strategies clearly planned: transit posts for population on move, special sessions in gated communities, hard to reach area
populations, etc
Maps show catchment areas for house to house teams; and location of fixed and special sessions (e.g transit) posts
Logistics and other resource estimations are complete; distribution plans are ready
List of local influencers/ leaders/ stakeholders along with their contact details, including potential support expected from them
Plan for bOPV/mOPV2 management and waste mangement in place
Logistics supply
Sufficient functional cold chain capacity and/or contingency plans for vaccine storage available
Adequate quantity of vaccine available
Adequate quantity of vaccine carriers, ice packs, zip lock bags available
Other logistics received: Finger markers, data tools and templates (tally sheets and reporting formats), banners
Logistics transport plan available to supply all areas
Contingency plan in place for replenishment of stocks run low
Social Mobilization
Barangay officials and other local leaders engaged for campaign announcements, conducted meetings, and support confirmed
Banners and other promotion material displayed
Community aware about the assigned date and venue of vaccination session in their area (survey 5 randomly selected eligible par
awareness)
Immunization safety
All supervisors know how to report AEFI
AEFI Investigation forms and SOPs available with supervisors
Supervision and monitoring
Monitoring and supervision plan available: details about areas selected, reason for selection, and monitors assigned
All supervisors and monitors are trained for conducting team monitoring, and RCAs
Required checklists and templates available
System to do mop ups in areas of failed RCAs in place
System for daily monitoring of coverage data and feedback from monitors; and using it for corrective actions
Reporting system
System for daily collection and consolidation of tally sheets, and monitoring feedback into reports
Mechanism in place for submission of reports (manual or electronic)
Mopv2/bOPV management
Logistics focal point assigned, and trained on mOPV2/bOPV management
Separate allocation of space for mOPV2/bOPV vaccine with clear labeling in refrigerators
All required recording and reporting templates available
System for vaccine recall, accountability, collection, handover and reporting to district/city level health office in place
Human resources
Adequate number of vaccinators, recorders (specify number for each)
All teams trained on specific infection prevention and control for COVID-19
All teams aware of recent guidelines on Polio campaign during COVID-19 pandemic response
Fully Achieved
Remarks
(Y/N)

Y
Y

Y
Y
N WALA PA ANG MASK, FACE SHIELD & ETC FROM REGION
Y
Y

Y
N WALA PA MI NATAGAAN OG ADD ON
N WALAY ZIPLOCKS
N ADDITIONAL TALLY SHEETS AND REPORTING FORMS
Y
N WALA PAKO KABALO KNG NAA BAI EXTRA ANG PHO

N WALA PA NA INFORM
N WALA PA MI KADAWAT OG TAGA-I

N WALA PA NA INFORM

Y
Y

Y
Y
N
Y
Y

Y
Y

Y
Y
Y
Y

N
Y
N