PLEASE FOLLOW THE INSTRUCTIONS:

1.) DO NOT INSERT OR DELETE ANY ROWS OR COLUMNS.

2.) FILL-OUT ONLY THE SHEET ASSIGNED PER MUNICIPALITY/CI
3.) CHOOSE THE STATUS OF YOUR PLAN FROM THE SCROLL DO
4.) IF YOUR PLAN IS ONGOING OR NOT DONE, KINDLY COMPLE
ON THE FOLLOWING COLUMNS INDICATING THE REASONS OF
UNACCOMPLISHED PLAN, ACTION PLAN, AND TARGET DEADLIN
COMPLIED.
5.) DEADLINE OF COMPLETION IS ON OR BEFORE OCTOBER 20
S.
LITY/CITY/AREA.
OLL DOWN CHOICES.
OMPLETE THE DETAILS
ONS OF
DEADLINE TO BE

BER 20, 2022.

 FORM 3. HEALTH FACILITY CAMPAIGN READINESS ASSESMENT TOOL (HEALTH CENTER LEVEL) FOR MR SIA
Region: ___IV-A______ Province: _______CAVITE________
City / Muncipality : _____TAGAYTAY CITY______ Target Population (9-59 months): __6,621____
LGU COVID-19 Zoning Status: _________________ Effective Dates of COVID-19 Zoning: ________________ Strategy (H2H/Fixed Posts/Mixed): _________________
Name of Monitor: _____________________ Agency: ___________ Respondent (Position): ____________________ Date of Visit/Assessment: ___________

1. Are all barangays, puroks and other areas are included in the health center microplan for catch-up immunization? YES
2. Are there plans to reach high risk populations included: high risk areas listed/identified, vaccination strategy identified, details about any
special arrangements available, areas are included in the monitoring and supervision plan YES
3. Are special strategies clearly identified for catch-up immunization: transit posts for mobile populations, special approach/sessions in gated
communities, other hard to reach areas etc YES
Microplanning 4. Do the HC/RHU/BHS Maps show catchment areas for house to house teams; and location of fixed and special sessions (e.g transit) posts YES
5. Are daily activity plans for the teams are available: indicating assigned areas, strategy used, estimated target population YES
6. Logistics and other resource estimations are complete; distribution plans are ready YES
7. List of local influencers/ leaders/ stakeholders along with their contact details, including potential support expected from them YES
8. Plan/protocol for immunization waste management in place YES
9. Barangay officials and other local leaders engaged for campaign announcements, conducted meetings, and support confirmed YES
10. Banners and other promotional materials received, reproduced & displayed in conspicous places of the community ONGOING
Social Mobilization
11. Community aware about the assigned date and venue of vaccination session in their area (survey 5 randomly selected eligible parents to
ONGOING
check awareness)
12. Adequate number of VTs (vaccinators, recorders & social mobilizers) organized & identified (specify number of VT for this facility) YES
Human Resource 13. All teams oriented on the campaign guidelines including key messages & communication for the VTs (IPCC) YES
14. All teams trained on specific infection prevention and control for COVID-19 YES
15. Sufficient functional cold chain capacity and/or contingency plans for vaccine storage available YES
16. Adequate quantity of MR and bOPV vaccines with diluents & droppers available YES
17. Adequte quantity of AD & mixing syringes YES
18. Adequate quantity of vaccine carriers, ice packs, zip lock bags available YES
Vaccine, Logistics 19. Adequate quantity of safety collector boxes (SCBs) YES
and Supply 20. Adequate finger markers NO
Management 21. Adequate PPEs (face masks, face shields), alcohols and cottons YES
22. Adequate AEFI/epinephrine kits YES
23. Adequate recording & monitoring tools and templates (tally sheets and reporting formats) YES
24. Logistics transport plan available to supply all areas YES
 Management

25. Contingency plan in place for replenishment of stocks run low YES
26. Barangay officials and other local leaders engaged for campaign announcements, conducted meetings, and support confirmed YES
Social Mobilization 27. Banners and other promotion material displayed ONGOING
28. Community aware about the assigned date and venue of vaccination session in their area (survey 5 randomly selected eligible parents to ONGOING
check awareness)
29. AEFI plan developed & referral facility identified with contact persons and contact numbers YES
Immunization
30. All supervisors know how to report AEFI YES
Safety
31. AEFI Investigation forms and SOPs available YES
32. Monitoring and supervision plan available: details about areas selected, reason for selection, and monitors assigned ONGOING
Supervision & 33. Supervisors have plans and are trained to conduct field supportive supervision YES
Monitoring 34. Required supervisory checklist available ONGOING
35. System/plan to do follow-ups & mop ups in areas with deferred, refusals and potentially missed children in place YES
36. System for daily monitoring of coverage data in place YES
Recording and
Reporting 37. System in place for daily collection and consolidation of tally sheets, and monitoring feedback reports YES
38. Mechanism in place for submission of reports (manual or electronic) to higher administrative level with focal person identified YES
Feedback and 39. System of daily feedbacking from VTS in place to discuss challenges and issues encountered in the field YES
Evaluation 40. System for daily feedback from monitors and using it for corrective actions in place YES
TOTAL
NO ZIP LOCK BAGS AVAILABLE
 FORM 3. HEALTH FACILITY CAMPAIGN READINESS ASSESMENT TOOL (HEALTH CENTER LEVEL) FOR MR SIA
Region: ___IV-A______ Province: _______CAVITE________
City / Muncipality : _____MAGALLANES_____ Target Population (9-59 months): __2385___
LGU COVID-19 Zoning Status: _________________ Effective Dates of COVID-19 Zoning: ________________ Strategy (H2H/Fixed Posts/Mixed): _________________
Name of Monitor: _____________________ Agency: ___________ Respondent (Position): ____________________ Date of Visit/Assessment: ___________

1. Are all barangays, puroks and other areas are included in the health center microplan for catch-up immunization? YES
2. Are there plans to reach high risk populations included: high risk areas listed/identified, vaccination strategy identified, details about any
special arrangements available, areas are included in the monitoring and supervision plan YES
3. Are special strategies clearly identified for catch-up immunization: transit posts for mobile populations, special approach/sessions in gated
communities, other hard to reach areas etc ONGOING
Microplanning 4. Do the HC/RHU/BHS Maps show catchment areas for house to house teams; and location of fixed and special sessions (e.g transit) posts YES
5. Are daily activity plans for the teams are available: indicating assigned areas, strategy used, estimated target population ONGOING
6. Logistics and other resource estimations are complete; distribution plans are ready YES
7. List of local influencers/ leaders/ stakeholders along with their contact details, including potential support expected from them ONGOING
8. Plan/protocol for immunization waste management in place YES
9. Barangay officials and other local leaders engaged for campaign announcements, conducted meetings, and support confirmed YES
10. Banners and other promotional materials received, reproduced & displayed in conspicous places of the community ONGOING
Social Mobilization
11. Community aware about the assigned date and venue of vaccination session in their area (survey 5 randomly selected eligible parents to
ONGOING
check awareness)
12. Adequate number of VTs (vaccinators, recorders & social mobilizers) organized & identified (specify number of VT for this facility) YES
Human Resource 13. All teams oriented on the campaign guidelines including key messages & communication for the VTs (IPCC) YES
14. All teams trained on specific infection prevention and control for COVID-19 YES
15. Sufficient functional cold chain capacity and/or contingency plans for vaccine storage available YES
16. Adequate quantity of MR and bOPV vaccines with diluents & droppers available YES
17. Adequte quantity of AD & mixing syringes YES
18. Adequate quantity of vaccine carriers, ice packs, zip lock bags available YES
Vaccine, Logistics 19. Adequate quantity of safety collector boxes (SCBs) YES
and Supply 20. Adequate finger markers NO
Management 21. Adequate PPEs (face masks, face shields), alcohols and cottons YES
22. Adequate AEFI/epinephrine kits YES
23. Adequate recording & monitoring tools and templates (tally sheets and reporting formats) YES
24. Logistics transport plan available to supply all areas YES
 Management

25. Contingency plan in place for replenishment of stocks run low YES
26. Barangay officials and other local leaders engaged for campaign announcements, conducted meetings, and support confirmed YES
Social Mobilization 27. Banners and other promotion material displayed ONGOING
28. Community aware about the assigned date and venue of vaccination session in their area (survey 5 randomly selected eligible parents to ONGOING
check awareness)
29. AEFI plan developed & referral facility identified with contact persons and contact numbers YES
Immunization
30. All supervisors know how to report AEFI YES
Safety
31. AEFI Investigation forms and SOPs available YES
32. Monitoring and supervision plan available: details about areas selected, reason for selection, and monitors assigned ONGOING
Supervision & 33. Supervisors have plans and are trained to conduct field supportive supervision YES
Monitoring 34. Required supervisory checklist available ONGOING
35. System/plan to do follow-ups & mop ups in areas with deferred, refusals and potentially missed children in place YES
36. System for daily monitoring of coverage data in place YES
Recording and
Reporting 37. System in place for daily collection and consolidation of tally sheets, and monitoring feedback reports YES
38. Mechanism in place for submission of reports (manual or electronic) to higher administrative level with focal person identified YES
Feedback and 39. System of daily feedbacking from VTS in place to discuss challenges and issues encountered in the field YES
Evaluation 40. System for daily feedback from monitors and using it for corrective actions in place YES
TOTAL