CBN Data For 2015 EFY

Region Amhara Zone South Gondar Report Month Hidar Report Year 2015 deremo H/C
Ser.n Zone,Woredas,
o cluster HC, HPs
GMP

Population
Total # of U2 Children # of Children Weighed Participation (%) # of NW % of NW # of UW % of UW
Girls Boys Total Girls Boys Total Girls Boys Total Girls Boys Total Girls Boys Total Girls Boys Total Girls Boys Total
1 Askumia 4811 122 121 243 68 79 147 0 0 0 64 78 142 0 0 0 4 1 5 0 0 0
2 deremo 4908 124 124 248 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 kanat 7728 195 195 390 112 116 228 0 0 0 100 104 204 0 0 0 8 7 15 0 0 0
4 semina 7481 189 189 378 49 56 105 0 0 0 49 56 105 0 0 0 0 0 0 0 0 0
5 H/C 0 0 0 0 27 18 45 0 0 0 26 18 44 0 0 0 1 0 1 0 0 0
6

7 Total 24927 630 629 1259 256 269 525 0 0 0 239 256 495 0 0 0 13 8 21 0 0 0
8
# of Quality
9 Cont'd # of SUM % of SUM Cooking demonstration
# of % of Reporting Kebele Review
food & meeting
# of # of % of Check 1
# of HF # of
cooking cooking Reportin nutrition HEWs HEWs HEWs
10 # of cooking demons. Participants expects Reporte
Girls Boys Total Girls Boys Total demons demons to report d HF
g Rate commite in the attendi attendin
tration tration Female Male Total es Woreda ng g 0
meeting
Askumia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

deremo 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

kanat 5 4 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

semina 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
H/C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Region: Amhara Report Zone: South Gondar Report Date:
Children 6-59 months Supplemented with
Children Dewormed Nutritional Screening for children 6-59 months and PLW
Vitamin A

Target Children 6-59 months (12.88%)

(B) 12-59 Months Supplemented

(A+B) # of children 6-59 months

6-59 months children Screening coverage

(A) 6-11 Months Supplemented

Screened with bilateral odema

# of Children 6-59 Months

# of Children 6-59 Months

# of Children 24-59 months

# of Children 24-59 months

Screened with no odema &

Screened with no odema &

Screened with no odema &

Target # of Children 24-59

# of Children 6-59 Months

# of Children 6-59 Months

Supplemented with Vit A

Total # of Children 24-59 months

MUAC 11.5 to < 12.5 cm

Total # of 6-59 months Children

Total # of children 6-59 Months

Total # of children 6-59 Months

identified SAM + MAM Cases

GAM Rate (SAM+ MAM) %

MUAC >= 12.5cm
Deworming Coverage (%)
Vitamin A Coverage ( %)

MUAC <11.5 cm
supplemented with Vit A
Total Population

Dewormed

Dewormed
with Vit A

with Vit A

months
Se Name of

Dewormed
r. Cluster HCs

Screened
No and Kebeles

(%)
8.49%
M

M
F

F
1 Askumia 4811 620 0 0 0 0 0 0 0 0.0 409 0 0 0 0 0 0 0 0 2 3 128 118 251 0 5 0
2 deremo 4908 632 0 0 0 0 0 0 0 0.0 416 8 3 11 3 0 0 0 0 0 1 20 9 30 0 0 0
3 kanat 7728 995 6 8 23 20 29 28 57 6.0 656 18 20 38 6 0 0 5 4 8 7 215 216 455 0 24 0
4 semina 7481 963 0 0 0 0 0 0 0 0.0 636 0 0 0 0 0 0 0 0 5 3 114 120 242 0 8 0
5 H/C 0 0 0 1 0 1 1 0.0 0 0 0 0 0 0 0 0 0 0 0 58 54 112 0 0 0

24927
10 total 3211 6 8 21 29 29 58 2.0 2117 26 23 49 2 0 5 4 15 14 535 517 1090 0 37 0
Cont'd Action SC Action OTP Action TSFP Action Counseling Tot
Scre # of
# of # of al # # of
Targe enin PL # of
PLW PLW of PL
t g W PLW
Scree Scree Scr W
Tot Tota PLW Cove Refe Recei
F M F M F M Total F M Total (3.37 ned ned een Cou
al l rage rred ved
> 23 < 23 ed nsele
%) PLW TSF IFA
cm cm PL d
(%) P
W

Askumia 0 0 0 0 0 0 0 0 0 0 0 0 8 0 8 0 8 0 3
deremo 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
kanat 0 0 0 0 0 0 0 0 0 0 0 0 0 40 5 45 0 45 0 4
semina 0 0 0 0 0 0 0 0 0 0 0 0 0 31 2 33 0 33 0 8
H/C 0 0 0 0 0 0 0 0 0 0 0 0 0 12 0 12 0 12 0 12
total 0 0 0 0 0 0 0 0 0 0 0 0 0 91 7 98 98 0 27
 5
4
3
2
1

6 total
Region:

H/C
kanat

semina
deremo
Askumia
No. HC & HPs

7
2
2
2
1
0
Total beginning of the month (A)

0
0
0
9
0
0
New
Amhara

MUAC or WFH/WFL (B)

Zone:

0
0
0
0
0
0
Bilateral pitting Oedema
(C)
Re-

0
0
0
0
0
0
Relapse (D)

0
0
0
0
0
0
Admissions admissions

Returned Defaulters (E)

9
0
0
9
0
0

Total Admissions
[(F)=B+C+D+E)]
South Gondar

0
0
0
0
0
0

Transfer-in from OTP,SC or

other facility (G)

9
0
0
9
0
0

Total Entry [(H)=F+G)]

5
2
1
2
0
0

0 Cured (I)
0
0
0
0
0

Died (J)
Report Prepared by:
Discharged

0
0
0
0
0
0

Defaulter (K)
0
0
0
0
0
0

Non-responder
(L)
0
0
0
0

Stabilised to OTP (M)

5
2
1
2
0
0

Total discharged [(N)=I+J+K+L]

2
0
0
2
0
0

Transfer-out to SC or other
Month/Year of Reporting

facility (O)
Monthly Statistics Report for SAM (OTP)

8
3
1
4
0
0

Total Exit [(P)=N+O)]

9
0
1
7
1
0

Total at the end of the month

[(Q)=A+H-P)]
4
0
1
1
1
1

Total # of OTP Sites

0
0
0
0
0
0

# of OTP sites Reported in the

month
0
0
0
0
0
0
Don't touched blue columns & cells of this data sheet the data insert only yellow columns

Reporting rate (%)

0
0
0
0
0
0

Cured rate (%)

0
0
0
0
0
0

Death rate (%)

0
0
0
0
0
0

Defaulter rate (%)

0
0
0
0
0
0

Non-responder rate (%)

 9
8
7
6
5
4
3
2
1

10
No. Woredas
Region:

Total beginning of the month (A)

Amhara
New

MUAC or WFH/WFL (B)

Zone:

Admissions

Bilateral pitting Oedema

(C)
Re-

Relapse (D)
admissions

Returned Defaulters (E)

Total Admissions
[(F)=B+C+D+E)]
South Gondar

Transfer-in from OTP,SC or

other facility (G)

Total Entry [(H)=F+G)]

Cured (I)

Died (J)
Discharged
Report Prepared by:

Defaulter (K)

Non-responder (L)

Stabilised to OTP (M)

Total discharged [(N)=I+J+K+L]

Transfer-out to SC or other
Monthly Statistics Report for SAM (SC)

facility (O)
Month/Year of Reporting

Total Exit [(P)=N+O)]

Total at the end of the month

[(Q)=A+H-P)]

Total # of OTP Sites

# of OTP sites Reported in the

month
Don't touched blue columns & cells of this data sheet the data insert only yellow columns

Reporting rate (%)

Cured rate (%)

Death rate (%)

Defaulter rate (%)

Non-responder rate (%)

 Immunization self-assessment tools for Health centers and health posts
Woreda: __________ HC: _______________ HP__________ Assessment
Month____________ Date_________
Y/N/NA

1.        Is immunization coverage and dropout monitored on monthly basis by kebele?

Is the health facility on the right track in immunization performance? (compare

2.      
achieved coverage and dropout rate with plan)
3.      Does the facility monitor EPI performance of the catchment HP/Gotes based on RED
  problem categorization and take actions according to their priority?
Is immunization monitoring chart available, correctly filled and updated for the
4.      
completed month?
Were all immunization sessions executed without interruption in
5.     
the completed month as per the plan? Number
 
Planned................ Number Excutted............
Has the health center conducted immunization review meetings as per the plan?
6.      
(check for the availability of the minutes)
7.      Has the health center conducted supportive supervisions for the health posts as per the
  plan? (Check for the standard checklist and feedback provided). (Enter NA for HP)
Does the facility have vaccine forecast for the fiscal year including minimum and
8.      
maximum of the month?
Does the health facility use vaccine request format for requesting vaccine? (Check
9.      
copy of VRF for the completed 3 months).
Is the vaccine balance updated every time vaccine received or issued? (check for the
10.    
last transaction)
Are all antigens in the fridge not expired and of VVM stage I and II? (Check
11.     
physically)
Were all vaccines sufficient (no stock out) in this month? (Conduct physical count of
12.    
vaccines in the refrigerator)
Is the wastage rate of each vaccine calculated for the last completed month? (Discuss
13.    
on the calculated wastage)
Is the fridge temperature recorded twice a day including daily maximum and
14.    
minimum? (check completed month record)
 Are temperature records of fridges with vaccine free of alarm in the last one month?
15.    
(Check from Fridge tag or records)
If no for Q#15, write # of High alarm____ # of low alarm____ (write yes <2 freeze
16.    
alarm)
Were appropriate actions taken for temperature alarms that occurred this week /
17.    
month?

18.     Was temperature review conducted for the completed month?

Has the facility sent a copy of reviewed and completed fridge temperature monitoring
19.    
record
Have weto WoHo at the
conducted end of themaintenance
preventive month? for refrigerator during the week/month?
20.    (Check for the cleanliness of the refrigerators, frosting, cleanliness of the panel of
SDD fridges etc.)
21.     Are there no wastes in my compound which are not completely burnt?

22.    Does the facility have standard immunization registration book and properly use it?

Does the facility have standard tally sheet and is using for every session, both outreach
23.   
and static sessions?
Are defaulters of this month tracked? # of defaulters identified_____ # of
24.   
defaulters tracked_____________
Are all action points for previous month self-assessment executed as per the action
25.   
plan?

Proportio
n of
Summary “Yes”
No
Yes responses
(Y*100/(
Y+N)

Summary of Major findings of Monthly Self-Assessment e

m
en
S. No Identified
Responsi Implementation Timeline ta
Root Cause of the problem Actions points
problems ble body
tio
n
1 sta
 2
3
4
5
Team members
1.      Name _______________________________________________ Signature ___________________________
Date ___________________
2.      Name _______________________________________________ Signature ___________________________
Date ___________________
3.      Name _______________________________________________ Signature __________________________ Date
___________________