tOPV Withdrawal Tally Sheet To be completed by independent monitor Region: District: Supervisor name: Supervisor phone number: Health Facility Name Date of # of tOPV vials In/out of the bOPV IPV present? Follow-up Comments if follow-up is Visit found cold chain? present? needed? necessary 1 In Out Yes No Yes No Yes No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 2 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 3 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 4 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 5 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 6 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 7 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 8 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 9 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ 10 Yes No Yes No Yes No ☐ In ☐ Out ☐ ☐ ☐ ☐ ☐ ☐ Total number of health facilities monitored: Number of health facilities that need follow-up: Number of health facilities with tOPV not withdrawn from cold chain: Number of health facilities with no bOPV : Number of health facilities with no IPV: Additional comments: Form for Transfer of tOPV from Health Structures to Disposal Site Date: Cold Chain Store or Service Point sending tOPV: Disposal Site Receiving Vaccine:
tOPV Withdrawal Tally Sheet To be completed by independent monitor Region: District: Supervisor name: Supervisor phone number: Health Facility Name Date of Visit # of tOPV vials found In/out of the cold chain? bOPV present? IPV present? Follow-up needed? Comments if follow-up is necessary 1 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 2 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 3 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 4 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 5 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 6 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 7 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 8 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 9 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 10 ☐ In ☐ Out ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No Total number of health facilities monitored: Number of health facilities that need follow-up: Number of health facilities with tOPV not withdrawn from cold chain: Number of health facilities with no bOPV : Number of health facilities with no IPV: Additional comments: Form for Transfer of tOPV from Health Structures to Disposal Site Date: Cold Chain Store or Service Point sending tOPV: Disposal Site Receiving Vaccine:
OPV-switch-Monitoring-guidelines-July2015.docx