TALLY SHEET FOR ROUTINE IMMUNIZATION SESSION (FOR ONE DAY)

DAILY TALLY SHEET FOR ROUTINE IMMUNIZATION SESSION

NAME OF CENTRE	UNION COUNCIL	NAME OF TALUKA	NAME OF DISTRICT

NAME OF VACCINATOR	MONTH	YEAR	DATE

ANTIGEN	LESS THAN 1 YEAR			12–23 MONTHS			2 YEARS & ABOVE			GRAND TOTAL
	MALE	FEMALE	TOTAL	MALE	FEMALE	TOTAL	MALE	FEMALE	TOTAL	MALE	FEMALE

PREGNANT LADIES & CHILD BEARING AGE WOMEN (CBAs)

ANTIGEN	PREGNANT WOMEN (PL)	TOTAL	NON-PREGNANT WOMEN (CBAs)	TOTAL
GRAND TOTAL

VACCINE CONSUMPTION AND VACCINE WASTAGE

VACCINE CONSUMPTION	BCG	HEP-B	bOPV	ROTA	PENTA	PCV13	IPV	TCV	MR	TD
RECEIVED (DOSES) (a)
ADMINISTERED (DOSES) (b)
CONSUMED (DOSES) (c)
WASTAGE (%) ((c − b) / c × 100)

ABOUT VACCINE	BCG	HEP-B	bOPV	ROTA	PENTA	PCV13	IPV	TCV	MR	TD
NO: OF DOSES PER VIAL	20	1	20	1	1	4	10	5	5	20
NORMAL RANGE WASTAGE %	50%	5%	20%	5%	5%	10%	10%	10%	20%	20%

DESIGNED & CREATED BY: RAZA MUHAMMAD DANDAN, EX-DISTRICT SUPERINTENDENT OF VACCINATION (EPI) SUKKUR

NAME OF VACCINATOR:

SIGNATURE OF VACCINATOR: