CCEM 2

1 HEALTH/EPI FACILITY QUESTIONNAIRE

FACILITY CODE:
For National Level use only.
Administrative levels and EPI facility information
1. Region: (name of Region) 6. Type of health facility:
III Mark only ONE box
2. Province: (name of Province) National Vaccine Store
PAMPANGA Regional Head Office
3. Municipality/City: (name of Municipality) Provincial Health Office
LUBAO
City Health Office
4. Barangay: (name of Barangay)
SAN.ISIDRO Rural Health Unit
Barangay Health Station
5. Name of (health) facility:
RHU-3 LUBAO Other

Health facility immunisation activities

7. Total population in area served by facility: 12.Reserve stock for all antigens: (in weeks)
(number of) 4-8 weeks
47320
8a. Vaccine storage: Check box below ONLY if the facility 13a. Mode of vaccine supply: Mark only ONE box
has a refrigerator or freezer, even if broken. Otherwise leave Delivered Both (delivered and collected)
blank.
Storage Collected Unknown

13b. Mode of transportation: Mark ALL boxes that apply

8b. Type of services provided Mark ALL boxes that By foot By car By boat
apply
By motorcycle By van/jeepney
Outreach immunisation services Others _____________________________________
Static immunisation services
9. EPI/Vaccination staff: Write number 14. Distance to vaccine supply source:
(in estimated hours and minutes of travel time)
12 LESS 1HOUR

10. Cold chain training during last two years: 15. Health care waste disposal: Mark ALL boxes that apply
(number of staff trained in CC/VM) Burn & bury
High temperature incineration
10 Septic tank
Collected and transported to higher facility
None
11.Resupply interval of vaccines:(in weeks) 16. Stock outs in past 3 months: Mark only ONE box
4 WEEKS Yes No
Health facility energy sources available to power cold chain equipment
17. Grid electricity availability: Mark only ONE box 19. Gas cylinder availability last 6 months:
None Mark only ONE box

Less than 8 hours per day Always available Not available

8 to 16 hours per day
More than 16 hours per day

18. Kerosene availability last 6 months: 20. Number of gas cylinders available:none
Mark only ONE box
Always available Not available

Person responsible for cold chain at the facility EPI Coordinators information

Name:NERISSA BALTAZAR Name: RITA ROSE MAGSINO R.N PHN

Designation:RURAL HEALTH MIDWIFE Mobile number: 09175890153
Mobile number:09204241926 Signature:
Email: Date (dd/mm/yyyy): 23/05/2014