In

Name of Dispensing Unit:

Reporting Period: From:

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No.

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2

3
4
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7
8

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2
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Remarks:

Completed by (Name, Date and Signature):

Approved by (Name, Date and Signature):

Distribution: First Copy to Store and Second Copy to remain with the pa
 Inter
Name of Dispensing Unit:
Reporting Period: From: T

Product Description

Family Planning- (RMNCH I)

Condoms (Male)
Condoms (Female)
Etongestrel-(Implanon) single rodw
subdermal Implant with Applicator -
68mg with Insertion/removal
IUCD (Intrauterine Contraceptive
accessories kit acting
Device) - Long (consumable)
(CU380 A)
Levonorgestrel (Jadelle)- 75mg/rod of 2
rod - Implant rod (subdermal) with
sterile insertion trocar
Levonorgestrel (D-Norgestrel) +
Ethinylestradiol + Ferrous Fumerate -
(0.15mg + 0.03mg
Levonorgestrel + 75mg)-tablet
(D-Norgestrel) - 0.75mg
- Tablet (Emergency Contraceptive
Pills)
Levonorgestrel (D-Norgestrel) - 0.03mg
- Tablet (Mini Pills)
Medroxyprogesterone Acetate -
150mg/ml in 1ml vial - Injection
(Aqueous suspension) (Depo Provera)

Neonatal and Child Health (RMNCH I

Albendazole - 400mg
Amoxicillin - 250mg - Tablet
- Tablet
(Dispersible)
Amoxicillin - 125mg - Tablet
(Dispersible)
Ampicillin Sodium - 250mg in Vial -
Injection
Ampicillin Sodium - 500mg in Vial -
Injection
Chlorhexidine digluconate - 7.1%
(contains 4% Chlorhexidine) - Gel
Ciprofloxacin - 250mg--10mg/ml
Gentamycin sulphate Tablet in 2ml
Ampoule - Injection
Gentamycin sulphate - 40mg/ml in 2ml
Ampoule - Injection
Oral Rehydration Salt - 20.5g for 1
Littre Preparation - Powder
Zinc - ORS co-pack - 2 sachets ORS
20.5mg/ml + 10 Zn 20mg dispersible tab
Tetracycline - 1% - Eye Ointment
Water For Injection - 10ml - Injection
Vitamin K1 (Phytomenadione) -
1mg/0.5ml ampoule - Injection
Zinc Sulphate - 20mg - Tablet ( scored
& Dispersable )
Syringes (Disposable) 3 parts, 5ml Luer
fitting with 23G needle
CalciumMaternal
Gluconate(RMNCH III)
- 10% in 10ml
ampoule - Injection
Magnesium Sulphate - 50% in 10ml
ampoule - Injection Maleate - 0.2mg/ml -
Methylergometrine
Injection
Mifeprostone + Misoprostol - (200mg
(1Tablet) + 200mcg (4 Tablets)) - Tablet
Misoprostol - 200mcg - Tablet
Misoprostol
Oxytocin - 10- 25mcg
Units/ml- Tablet
in 1ml ampoule
injection
Ferrous +- Injection
Folic Acid - (60mg +
400mcg) - Tablet

Anti-Malaria Medicines
Artemether + Lumefanthrine -
20mg+120mg (6x1)
- Tablet (Dispersible)
Artemether + Lumefanthrine -
20mg+120mg (6x2)
- Tablet (Dispersible)
Artemether + Lumefanthrine -
20mg+120mg (6x3)
- Tablet(Coartem
Artemether 6x3)
+ Lumefanthrine -
20mg+120mg (6x4)
-Artesunate
Tablet(Coartem 6x4) in 1ml Ampoule -
- 60mg/ml
Injection
Artesunate - 100mg - Rectal
Suppository
Chloroquine Phosphate - 250mg -
Tablet
Chloroquine Phosphate - 50mg/ml in
5ml syrup Phosphate - 7.5mg base -
Primaquine
Tablet
Remarks:

Completed by (Name, Date and Signature):

Approved by (Name, Date and Signature):

Distribution: First Copy to Store and Second Copy to remain with the pad
Internal Facility Report and Resup
Maximum Stock Leve
To: Minimum Stock Level
Completed By Unit

Unit of Beginning Quantity

Issue Balance Received

A B

Piece
Piece

Each
Each
 Each

Cycle

Cycle
Cycle

Vial

MNCH II)
100
10x10
10x10
 50
50
21gm
10x10
50
50
Sachet

Pack
4gm
50
3
10x10
100
 10
10
10

Pack
28
4
10
100
 30

30

30

30
vial
2
10x10
60ml
10x10
the pad
nd Resupply Form (IFRR)
m Stock Level (ML)=
Stock Level (ML)=
mpleted By Unit

Loss/
Ending Balance
Adjustment

C D
FRR)

Completed By Store

Calculated Maximum
Consumption Quantity

E= F=
A + B +/– C–D E*2
Completed by (Name, Date and Signature):
pleted By Store

Quantity
Quantity to be
Needed to
Supplied
Reach Max
G=
H
F-D
e and Signature):

August 2020