🚙 Check list No: 02, for EPI-cold chain report

CHECK LISITNO:02,FOR EPI-COLD CHAIN REPORT

NAME OF VISITOR	DESIGNATION	DATE OF VISIT	TIME OF VISIT
NAME OF EPI CENTRE	UNION COUNCIL	TALUKA	DISTRICT
NAME OF VACCINATOR(1)	NAME OF VACCINATOR(2)	NAME OF VACCINATOR(3)	NAME OF VACCINATOR(4)

S.NO:	DETAIL	ILR-1	ILR-2	DEPFREEZER	REMARKS
01	Temperature of Refrigerator
02	Refrigerator was clean (Yes/No)
03	Temperature Chart is available (Yes/No)
04	Temperature Chart was filled updated (Yes/No)
05	Vaccines Stored in Refrigerator according to EPI Policy (Yes/No)
06	Fridge Tag is available in Refrigerator (Yes/No)
07	Fridge Tag Working Properly (Yes/No)
08	Voltage Stabilizer is available with Refrigerator (Yes/No)
09	Voltage Stabilizer working properly (Yes/No)
10	Refrigerator wooden chowki is available (Yes/No)
11	Electric switches of Refrigerator/Voltage Stabilizer covered with Tape (Yes/No)
12	No:of Vaccine Vials/Amp: are available according to Record (Yes/No)
13	No:of BCG/MR Dailuent are available according to Vaccine vials (Yes/No)
14	No: of BCG Vaccine Ampules Available in Refrigerator
15	No: of BCG Daluent Ampules Available in Refrigerator
16	No: of BCG Vaccine Ampules Available in Record
17	No: of BCG Daluent Ampules Available in Record
18	No: of MR Vaccine Ampules Available in Refrigerator
19	No: of MR Daluent Ampules Available in Refrigerator
20	No: of MR Vaccine Ampules Available in Record
21	No: of MR Daluent Ampules Available in Record
22	No: of bOPV Vaccine Vials Available in Refrigerator
23	No: of bOPV Vaccine Vials Available in Record
24	No: of ROTA Vaccine Tubes Available in Refrigerator
25	No: of ROTA Vaccine Tubes Available in Record
26	No: of Hepatitis-B Vaccine Ampules Available in Refrigerator
27	No: of Hepatitis-B Vaccine Ampules Available in Record
28	No: of PENTA Vaccine Vials Available in Refrigerator
29	No: of PENTA Vaccine Vials Available in Record
30	No: of PCV13 Vaccine Vials Available in Refrigerator
31	No: of PCV13 Vaccine Vials Available in Record
32	No: of IPV Vaccine Vials Available in Refrigerator
33	No: of IPV Vaccine Vials Available in Record
34	No: of TCV Vaccine Vials Available in Refrigerator
35	No: of TCV Vaccine Vials Available in Record
36	No: of TD Vaccine Vials Available in Refrigerator
37	No: of TD Vaccine Vials Available in Record
38	Vaccine Consuption Register was available (Yes/No)
39	Vaccine Consuption Register was updated (Yes/No) If no write last date
40	No: of Vaccinators posted at this centre
41	No: of Vaccine Carriers are available at Centre
42	No: of Vaccine Carriers are available in Record
43	No: of Ice Packes for V/C available in ILR/Deepfreezer
44	No: of Ice Packes for V/C available out of ILR/Deepfreezer
45	No: of Ice Packes for V/C available in Record
46	No: of Cold Box available Centre
47	No: of Cold Box available in Record
48	No: of Cold Box Ice Pakes available in ILR/Deepfreezer
49	No: of Cold Box Ice Packes available out of ILR/Deepfreezer
ABSORVATIONS OF VISITERS

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

SIGNATURE OF VISITOR