VHW ID Number:_________________ VHW Name:_____________________________ Village:__________________ TA:___________________ HSA Name:__________________________ Date Chart Opened:_____________________
SECTION 1
LIST ALL HOUSEHOLD MEMBERS AND FILL IN THE REQUESTED INFORMATION
First Name
Last Name
Male/ Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
HSA MONTHLY REPORT
DO NOT FILL
Date of Birth ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year ________/________/________ Day Month Year
Aug
Sep
Oct
Over 15?
Ever tested ...in the past 6 for HIV? months?
Nov
Dec
Jan
HYGEINE / SANITATION
Joined Household
Left Household
Died
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
Borehole
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
Protected Well
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
Do they have a pit latrine?
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
Yes No
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
__________/__________ Month Day
HSA MONTHLY REPORT (CONTINUED) Number of new coughers this month (SECTION 3)
Number of people over 15 not tested for HIV (SECTION 1)
Number of patients whose cough has not improved (SECTION 3)
Number of people over 15 not tested for HIV in the past 6 months (SECTION 1)
Number of coughers not improved who have not submitted sputum (SECTION 3)
Number of men not using family panning
Number of patients reactive (SECTION 4)
Number of women currently pregnant
Number of patients reactive and not in pre-art nor on ARVs (SECTION 4)
Number who have not started ANC
Number of children in reactive households not tested (SECTION 4)
Number without ANC in the past two months
Number of children under 1 not tested (SECTION 4)
Number without a net
Number of women over 15 not using family planning
Number not tested for HIV Number HIV positive Number HIV positive not in PMTCT Number delivered this month Number delivered at home Number of post-partum PMTCT mothers without a 6-month EID visit
Children under 5 SECTION 6
Pregnant Women SECTION 2
Number not tested for HIV (SECTION 1)
Number of children under five Number over one without pentavalent 3, polio 4, or measles vaccine Number without a net Number with Yellow or Red MUAC Number with Yellow or Red MUAC not enrolled in food program Number with Yellow or Red MUAC enrolled in food program not tested for HIV
Aug
Where do they get their water?
River Tap Protected Spring Other: ___________
Sep
Oct
Nov
Dec
Jan
SECTION 2
LIST ANY WOMAN WHO IS PREGNANT OR DELIVERED WITHIN THE PAST 2 MONTHS ANC Visits
PMTCT
Used Net
MUAC
Name
Food Program
HIV Test
1
2
3
4
____/____
____/____
____/____
____/____
Day Month
Day Month
Day Month
Day Month
____/____
____/____
____/____
____/____
Day Month
Day Month
Day Month
Day Month
_____/_____ Day Month
_______ Year
NR
/
R
_____/_____ Day Month
_______ Year
NR
/
R
_____/_____ Day Month
_______ Year
NR
/
Day Month
Home
Mother Died
________ Year
Miscarriage
Baby Died
Day Month
Home
Mother Died
________ Year
Miscarriage
Baby Died
____/____
____/____
____/____
Day Month
Day Month
Day Month
Day Month
Day Month
Home
Mother Died
________ Year
Miscarriage
Baby Died
LIST ANYONE WITH COUGH OR FEVER OR BOTH AT ANY TIME IN THE PAST 4 WEEKS
Name
COMPLETE AT FOLLOW-UP VISIT Accompanied to Health Date Seen at Received Improved Sputum Given Facility? Health Facility TB Treatment
Yes
No
Yes
No
Yes
No
Yes
No
Yes
SECTION 4
_________/_________ Day/Month _________/_________ Day/Month _________/_________ Day/Month
_________/_________ Day/Month
_____/_____
Day Month
Day Month
After 2 Weeks _____/_____
_____/_____
Day Month
Day Month
Family Planning Method
Male/ Female
Name
Male Female
_____/_____/_____
_____/_____/_____
No / R / NR No / R / NR
Next Appointment
Male Female Male
Day / Mwez I /Year
Female
Day / Mwez I /Year
_____/_____/_____ Day / Mwez I /Year
_____/_____/_____
_____/_____/_____
Male
Day / Mwez I /Year
Female
•Condoms
•Injection
•Pills
•IUD
•Norplant •None
•Tubal Ligation
•Condoms
•Injection
•Pills
•IUD
•Norplant
•Tubal
•None
Ligation
•Condoms
•Injection
•Pills
•IUD
•Norplant •None
•Tubal Ligation
•Condoms
•Injection
•Pills
•IUD
•Norplant •None
•Tubal Ligation
•Condoms
•Injection
•Pills
•IUD
•Norplant
•Tubal Ligation
•None
Day / Mwez I /Year
LIST ANY CHILD WHO IS LESS THAN FIVE YEARS OLD
Pentavalent DPT/HBV/HIB 1 2 3
Oral Polio 0
1
2
3
Measles
BCG
Used Net
Under Tested 1 Year for HIV
Name
_____/_____
LIST ANYONE BETWEEN 15 AND 49 YEARS OLD
SECTION 5
ARVs
Partner Tested
No / R / NR
SECTION 7
After 2 Weeks
Female
PREART
No. of Untested Children under 1
No / R / NR
Name
Day Month
Male
Bactrim
No. of Untested Children under 15
No / R / NR
SECTION 6
_____/_____
Day Month
LIST ANYONE WHO IS REACTIVE Used Net?
Name
No
_________/_________ Day/Month
_____/_____
Health Facility Both Alive ____/____
6-week EID Visit
After 2 Weeks
Health Facility Both Alive ____/____
SECTION 3
Postnatal Visit 1
Health Facility Both Alive ____/____
____/____
R
Baby and Mom
Delivery Delivery Date Location
MUAC 1
2
3
4
5
6
Green
Green
Green
Green
Green
Green
Yellow
Yellow
Yellow
Yellow
Yellow
Yellow
Red Green
Red Green
Red Green
Red Green
Red Green
Red Green
Yellow
Yellow
Yellow
Yellow
Yellow
Yellow
Red Green
Red Green
Red Green
Red Green
Red Green
Red Green
Yellow
Yellow
Yellow
Yellow
Yellow
Yellow
Red Green
Red Green
Red Green
Red Green
Red Green
Red Green
Yellow
Yellow
Yellow
Yellow
Yellow
Yellow
Red Green
Red Green
Red Green
Red Green
Red Green
Red Green
Yellow
Yellow
Yellow
Yellow
Yellow
Yellow
Red
Red
Red
Red
Red
Red
Referred to Health Facility
Begin
End
____/____
____/____
____/____
Day / Month
Day / Month
Day / Month
____/____
____/____
____/____
Day / Month
Day / Month
Day / Month
____/____
____/____
____/____
Day / Month
Day / Month
Day / Month
____/____
____/____
____/____
Day / Month
Day / Month
Day / Month
____/____
____/____
____/____
Day / Month
Day / Month
Day / Month
Food Program
REFERRALS AND ACCOMPANIMENT Accompanied to Health Facility
Date
Reason for Accompaniment •HIV
Testing
______/______ Day/Month •Postnatal
______/______ Day/Month •Postnatal
______/______ Day/Month •Postnatal
Visit •HIV Testing Visit •HIV Testing •HIV
Visit Testing
______/______ Day/Month •Postnatal
Visit
•ANC
•Malnourished
•Immunization
•ART
•EID
•Needs
•Family
•ANC
Net •Malnourished
Planning •Immunization
•EID
•Needs
•Family
•ANC
Net •Malnourished Net
Date Evaluation
HSA /
•Other:
_____/_____ Day/Month
Planning •Immunization
•Other:
_____/_____ Day/Month
Site Coordinator
•Family
•Other:
_____/_____ Day/Month
Site Coordinator
_____/_____ Day/Month
Planning
_______________ •ART Evaluation •Cough _______________ •ART Evaluation •Cough
•EID
•Needs
•ANC
•Malnourished
•Immunization
•ART
•EID
•Needs
•Family
•Other:
Net
•Cough
30-day Followup Seen at Discussed Heath With... Facility
Planning
_______________ Evaluation •Cough _______________
Site Coordinator HSA / HSA / HSA / Site Coordinator