TY MALARIA COMMODITY ORDER AND REPORTING FORM

REPORTING PERIOD (2 MONTHS)

Facility Name & Level of Care : KISARU TEA HC II

District: KIKUUBE START DATE: 1-Jun-23

31-Jul-23
Delivery Zone: 4 END DATE:

Cycle Number: 3 DATE PREPARED : 2-Aug-23

AND REPORTING INFORMATION

Average Monthly
Consumption (Quantity Number of Days Out of Consumption Quantity Requested/Qty
OPENING BALANCE (Stock on Qty Received from Closing Balance at End Months of Stock
Product Name and Specification Unit Size Start date to End dat Issued from Store) from Adjustments (+/-) Stock from Start date to =
to Order Remarks (refers Closing Balance
Hand) at Start date (i.e. the date =Physical
start of 2 months cycle) (i.e. During 2 month Start date to End date End date (i.e.
= count in store = (G/F)
= to all relevant issues and explanations of adjuments) Validation
Cycle) (i.e. During 2 month During 2 month Cycle) (F x 4) - G
Cycle)
=
Stock card / Stock Stock card / Stock
Source Stock card / Stock book Stock card / Stock book Stock card / Stock book Physical Count
book book
A B C D E F G H I
Uncomplicated Malaria
Artemether - Lumenfatrine
1 (20/120mg tab) - 6x1 (Yellow) Pack of 30 strips 89 420 175 0 0 87.5 334 3.8 16 TRUE
Artemether - Lumenfatrine
2 (20/120mg tab) - 6x2 (Blue) Pack of 30 strips 0 0 0 60 #DIV/0! #DIV/0!
Artemether - Lumenfatrine
3 (20/120mg tab) - 6x3 (Brown) Pack of 30 strips 0 0 0 60 #DIV/0! #DIV/0!
Artemether - Lumenfatrine
4 (20/120mg tab) - 6x4 (Green) Pack of 30 strips 33 810 400 0 0 200.0 443 2.2 357 TRUE
Complicated Malaria
Artesunate Injection (IV/IM) 60mg
5 Vial 0.0 -
Artesunate Rectal Suppositories
6 100mg Piece 0.0 -
Artesunate Rectal Suppositories
50mg Piece 0.0 -
Sulfadoxine/Pyrimethamine
7 200/25mg (Fansidar) Tin of 1000 0.0 -
Mosquito Nets (LLINs)
8 Piece 0 150 79 50 15 52.7 0.0 90 Received from Kikuube H/C IV

Lab
Malaria Rapid Diagnostics Test
9 (mRDTs) Pack of 25 Test strips 0 2475 751 176 30 751.0 1,900 2.5 1,104 TRUE

Patient Summary Data for the 2 months period (i.e. from Start to end date)
Malaria Total OPD Malaria Total IPD Number of Malaria RDT
done
{Note: (Note: Positive & Negative)
{Note: Should include cases from OPD,
Should include cases from Data Source: HMIS Form
ANC, HIV Clinic, Outreaches etc.) Data Maternity) Data Source: HMIS
Source: HMIS Form 105 (Section 1.3) 105 (Section 7.3)
Form 108 (Section 6)
Month 1 Month 2 Month 1 Month 2 Month 1 Month 2

224 319 17 15 269 482

Ordered by: JUSTINE N Designation: N/O Mobile: 701539157 Signature:

Approved by: Designation: Mobile: Signature:

Please Affix the facility/IP stamp for Authority

Submit to: sales@jms.co.ug/sales.jms2@gmail.com

 IMPLEMENTING PARTNER REPRODUCTIVE HEALTH PRODUCTS REPORT AND REQUISITION FORM

Request Date : IP name :

Physical address : District:

Phone contacts : Delivery zone:

Contact Person : Name :

Period (month): e-mail address :

Phone Number :

Minimum stock level (months of stock) 2 Maximum stock level (months of 6

stock)

Closing Balance Quantity DISTRIBUTED Quantity ISSUED LOSSES /

during the last for the last two ADJUSTMENTS
Product name and specification Pack Minimum month (Physical for the last two months from Months of Stock on during the last
Quantity Requested=
size/Unit order qnty months from stock hand [A/(B/2)] month [(2X(B+C))-A]
Count in Stores + taken from UHMG stock taken from
Pharmacy) UHMG (+/-)

A B C D E F
1 Combined Oral Pill eg Microgynon tablets cycles pack of 3

2 Progestin only pills eg Microlut tablets cycle pack of 3

3 Female condoms piece 1000

4 Male condoms piece 5760

5 2 rod implants eg Jadelle Implants piece 100

6 1 rod implant eg Implanon Implants piece 64

7 Injcetable Contraceptive IM eg Depo-Provera vial 400

10 Copper T IUD piece 50

11 Injcetable Contraceptive SC eg Sayana Press vial 200

12 Emergence Contraceptives Tablets 1 packet

13 Water-Base Sex Lubricant Tubes 50's

14 Misoprostol piece 1's

Issued By ____________________________________________________________ (Sign and Date)

Recieved By ____________________________________________________________(Sign and Date)

 REPRODUCTIVE HEALTH PRODUCTS REPORT AND DISTRIBUTION ACCOUNTABILITY FORM

Distribution Cycle :

Institution name :

Physical address :

Phone contacts :

Contact Person : Name :

e-mail address :

Phone Number :

FACILITY INFORMATION PRODUCT UTILISATION REPORT ORDER INFORMATION

Quantity
Reported in Quantity
Facility Product Pack size/Unit of consumed Stock on Months HMIS 105 Risk of Requested by Quantity
Date Name Facilty Level District Name measure in the hand of Stock last Month Expiry (Y/N) Health supplied by IP Remarks
Previous
(Y/N) facility
Month
 Prepared By ____________________________________________________________ (Sign and Date)

Approved By ____________________________________________________________(Sign and Date)

Approved By
____________________________________________________________(Sign and Date)