DAILY SUMMARY REPORTING FORM

Daily Consolidated Sheet for City/Municipal HCs or RHUs (To be reported to the Province/City)

Region: _________ Province: ______________ City/Municipality: ________________________

District: _________________ Health Center/RHU: _____________________ Date: _________________

MR bOPV MR Coverage bOPV Coverage bOPV

Purok/Barangay Target Target (Number of Children Immunized) (Number of Children Immunized) No. of No. of MR Vaccine Utilization ( In Vials) Vaccine Utilization ( In Vials)
Deferred Refusals
9-11 mos 12-59 Grand % 0-11 12-59 Grand % Received Unus Used Partially Received Unused Used Partially
mos Total mos mos. Total ed (Empty) Used (Empty) Used

TOTAL

*Partially Used Vials –shall be discarded (after 6 hrs. or at the end of immunization session whoever comes first) but need to be accounted