EPI - Outreach Site RI Monitoring Checklist

Name of the Monitor: Date:

UC: Town/ Tehsil:

District: Area/Village Name:

Name of Vaccinator at outreach: Name of LHW at outreach:

Please tick against each question in ‘Yes’ or ‘No’ column Yes No

1 Updated outreach plan available with vaccinator?

2 Session conducted as per outreach plan of vaccinator?

3 Is this area/village covered by LHW?

4 Is LHW/CBV available in session for community awareness?

a) If yes, please mention who is available in session LHW or CBV?

5 List of previous month defaulter children available with vaccinator?

# of # of
defaulter defaulter
recorded covered
Number of defaulter children of this area/ village recorded and covered by vaccinator as per
6
list

List of zero dose RI children recorded in last Polio SIAs available? (Please do Not ask for zero
7
dose list of current month Polio SIAs)
# of zero # of zero
dose dose
recorded covered
8 Number of zero dose children of this area/ village recorded and covered by vaccinator as per
list

9 Does the vaccinator have a standard vaccine carrier with 4 cool packs and foam pad?
10 All Antigens are available for RI (OPV, IPV, MCV, Penta, PCV, Td, TCV and Rota)

a) If no, which antigen is missing?

b) Date & time mentioned on the opened/ reconstituted vial of MCV, IPV, PCV-10 and Td
as these antigens have to be discarded at the end of session
c) If no, mention name of opened/reconstituted antigen on which date & time is not
mentioned
11 Is there any vaccine with unusable VVM?
If yes, please mention quantity of unusable VVM vaccine)
OPV_____ IPV_____ MCV_____ Penta_____ PCV_____ Td_____ TCV_____ Rota_____

12 Is there any expired date vaccine?

If yes, please mention quantity of expired vaccine
OPV_____ IPV_____ MCV_____ Penta_____ PCV_____ Td_____ TCV_____ Rota_____
13 Is a safety box being used to dispose used syringes?
Does the vaccinator ask if the child ever had a severe reaction after a previous vaccine
14
injection?
Does the vaccinator provide information to mothers about possible side effects (AEFIs) such as
15
fever or pain after injection?
16 Does the vaccinator have an AEFI form available to report possible AEFI?

17 Does the vaccinator know what to do when any AEFI occurs?

18 Does the vaccinator inform the mother/ caregiver about the next visit?
19 Did the vaccinator receive POL of last month?

20 Is vaccinator using Zindagi Mehfooz (ZM) android App for reporting at the time of visit?
Overall comments

Feedback given to Vaccinator, HF Incharge, TSV, DSV, EPI Focal Person, THO, DHO, DPCR:
a) Reason for not sharing feedback with concerned persons

Monitor’s Signature:
Note: Vaccinator means any person, giving vaccination to the children/Pregnant woman/ CBA