Monthly Performance Report

Month: Name of FWC:

Rental Status: No. of C.S Reffered No. of C.S Performed

No. of Implant Referred: No. of Implant Performed: No. of Women Counseled:

Contraceptives:
Contraceptive Opening Received From Issued from Issued in Issued by Total Closeing
Total
Name Balance DWP Office FWC Camp FWAs/Others Issued Balance
4 8
1 2 3 5 6 7 9
(2+3) (5+6+7)
Condom
POP
COC
ECP
Cu-t
Injection

Clients
Contraceptive Total New Total Old
FWC Clients FWAs Clients Camp Clients Total
Name Clients Clients
7
1 2 3 4 5 6
(4+5+6)
Condom
POP
COC
ECP
Cu-t
Injection

General Patients Details:

Patients at FWCs/MSUs Patients at Camps Total
A.N
P.N
Children
General
C.S F/up
Implant F/up

Eligible Couples:
New During the Month Old upto Previous Month Total
FWA (Female)

Health & Hygiene Session Conducted: No. of Advocacy Meeting:

No. of Motivational Visits FWA (M): No. of Motivational Visits FWA (F):

Total Clients Clients of FWA & Camp: Total Chit Money:

Equipments Status:
Requirement of Equipment
S.No Name of Equipment Quantity Missing Out of Order
if any
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Medicines:
Opening Received From Issued During the
S.No Name of Medicines Closeing Balance
Balance DPW Office Month
1 Tab: Dymin
2 Tab: Pedral
3 Tab: Flagyl
4 Tab: Kemic
5 Tab: Pirition
6 Syp:Amoxil
7 Syp: Para
8 Syp: Ket
9 Syp: Riam/Flagyl
10 Cap: Amoxil
11 Syp: Cough
12 Syp: F.S
13 Polyfex
14 Syp: Manacid
15 Pyodine
16 Cotton
17 Chlorine Solution
18 Tab: Bendazol
19 Syp: Dymin
20 O.R.S
21
22
23

Name of Incharge: Signature:

Date of Submission: