Professional Documents
Culture Documents
Hydroxy-Chloroquine Prophylaxis PDF
Hydroxy-Chloroquine Prophylaxis PDF
Scanned by CamScanner
Format I - List of Health Staff under Hydroxy -Chloroquine Prophylaxis
Name of the HUD: Name of the PHC: Date:
Consumption details
if any
If anyone
Adverse
reported
events
COVID-19
Name of the reported
S.No Designation Mobile Number symptoms,
Heath Staff Day 1 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 (Yes or
(Yes or No).
No). If yes
If yes , Give
, Give
details
details
Consumption details
If anyone
if any Adverse
Name of the reported COVID-
events
Asymptomatic 19 symptoms,
S.No Address Mobile number reported, (Yes
Household Day 1 Week 1 Week 2 Week 3 (Yes or No). If
or No) If yes ,
Contacts yes , Give
Give details
details
Name of Household
the Health Staff Frontline worker Total
S.N contacts Opening Closing
Primary Utilized
o Balance Balance
Health As on date Upto date As on date Upto date As on date Upto date As on date Upto date
Centre