CHECK LIST NO: 05, FOR EPI HOUSE TO HOUSE FIELD VISIT SUMMARY

NAME OF VISITOR
DESIGNATION
DATE OF VISIT
TIME OF VISIT
NAME OF VILLAGE/MUHALLA/STREET
NAME OF UNION COUNCIL
NAME OF (EPI) CENTRE
NAME OF VACCINATOR (THIS AREA)
NO:OF HOUSES VISITED
NO:OF CHILDREN CHECKED
NO:OF CHILDREN BCG SCAR WAS VISIBLE
% OF BCG SCARS
NO:OF FULLY IMMUNIZED CHILDREN
% OF FULLY IMMUNIZED CHILDREN
NO:OF PARTIALY VACCINATED
% OF (PI) CHILDREN
NO:OF DEFAULTERS FOUND
% OF DEFAULTERS CHILDREN
NO:OF UNVACCINATED CHILDREN FOUND
% OF UNVACCINATED CHILDREN
NO:OF V.CARDS AVAILABLE
% OF V.CARDS AVAILABLE
NO:OF V.CARDS NOT AVAILABLE
% OF NOT AVAILABLE V.CARDS
OBSERVATIONS:

DESIGNED BY:-RAZA MUHAMMAD,DANDAN,EX-DSV (EPI)

SIGNATURE OF VISITOR