Request Form for EPI Tools for Counties with Shortages

Date of Request:

County Abiemnom County Baliet

# of HFs CHD # of HFs CHD
in need Cold in need Cold
S/No Item Description Unit Chain Quantity Remarks S/No Item Description Unit Chain Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

County Bor South County koch

# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

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County Leer County Longechuk
# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

County Maiwut County Malakal

# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

Page 2
County Mayendit County Manyo
# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

County Fashoda County Nasir

# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

Page 3
County Pariang County Pibor
# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

County Pigi County Pochalla

# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece

Page 4
 11 Infant Register Booklet 11 Infant Register Booklet

County Raja County Ulang

# of HFs CHD # of HFs CHD
in need Cold in need Cold
Chain Chain
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity Remarks
1 Vaccine Control Books Book 1 Vaccine Control Books Book
2 Fridge Tag Piece 2 Fridge Tag Piece
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet
5 Tally Sheet Booklet 5 Tally Sheet Booklet
6 TD Cards Piece 6 TD Cards Piece
7 TD Register Piece 7 TD Register Piece
8 Child Health Cards Piece 8 Child Health Cards Piece
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece
11 Infant Register Booklet 11 Infant Register Booklet

County Uror Total Quantities Requested

# of HFs CHD
in need Cold
Chain Total
S/No Item Description Unit Quantity Remarks S/No Item Description Unit Quantity
1 Vaccine Control Books Book 1 Vaccine Control Books Book -
2 Fridge Tag Piece 2 Fridge Tag Piece -
3 Temperature Monitoring Chart Piece 3 Temperature Monitoring Chart Piece -
4 Monthly Reporting Book Booklet 4 Monthly Reporting Book Booklet -
5 Tally Sheet Booklet 5 Tally Sheet Booklet -
6 TD Cards Piece 6 TD Cards Piece -
7 TD Register Piece 7 TD Register Piece -
8 Child Health Cards Piece 8 Child Health Cards Piece -
9 Defaulter Tracing Cards Piece 9 Defaulter Tracing Cards Piece -

Page 5
10 EPI Monitoring Chart Piece 10 EPI Monitoring Chart Piece -
11 Infant Register Booklet 11 Infant Register Booklet -

Name: Position: Sign:

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