15 16 17 18 19 Total *Write one of the following types of facilities: National store, Regional store, District store, Service Point (SP) Form may be modified as needed to suit needs of country. tOPV Disposal Form Supervisors – (Monitor fills out) Disposal Site Name: Supervisor name: Supervisor phone number: Region: District: Disposal Level of Region District Date tOPV # of tOPV Date tOPV # of tOPV Date tOPV # of tOPV Site Disposal of Visit Disposal vials of Visit Disposal vials of Visit Disposal vials Name Site* Completed? disposed Completed? disposed Completed? disposed of to date of to date of to date 1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 Total *Write one of the following types of facilities: National store, Regional store, District store, Service Point (SP) Form may be modified as needed to suit needs of country. tOPV Disposal Form – Supervisors (Monitor fills out) Disposal Site Name: Supervisor name: Supervisor phone number: Region: District: Disposal Site Name Level of Disposal Site* Region District Date of Visit tOPV Disposal Completed? # of tOPV vials disposed of to date Date of Visit tOPV Disposal Completed? # of tOPV vials disposed of to date Date of Visit tOPV Disposal Completed? # of tOPV vials disposed of to date 1 2 3 4 5 6 7 8 9 10 11 12 13 14
OPV-switch-Monitoring-guidelines-July2015.docx