Na FORMAT A

me
of
(LINE LISTING OF HOUSE HOLDS)
the
Vill
age
:
Name of the ASHA: Mobile No:
Name of the team supervisor and designation: Mobile No:

S.No HOUSE NUMBER Total Number of family Number of HH members returned from
members in HH the foreign on or
after 10th February 2020

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
SIGNATURE OF ASHA NAME OF THE SUPERVISORY OFFICER
FICER
 FORMAT B
(LINE LISTING OF PERSONS RETURNED

Name of the Village:

Name of the ASHA: Mobile No:
Name of the supervisory: Mobile No:
S.No House No Name of the person Age Sex Phone
Number

SINGANTURE OF ASHA SINGATURE OF SUPERV

 FORMAT B
OF PERSONS RETURNED FROM FOREIGN)

Mobile No:
Mobile No:
Date of arrival to Country from Whether
India which Symptomatic
returned (Yes/No)

SINGATURE OF SUPERVISORY OFFICER

 FORMAT C
(HEALTH STATUS MONITORING OF FOREIGN RETURNEES)
Mobile No:

Name of the PHC

Name of the Medical Officer Mobile No:
S.No Name of the foreign Age Sex Date of arrival Wh
returnee to India
th
12
March

*till completion of 28 days

SINGANTURE OF ASHA SINGATURE OF
IGN RETURNEES)

Mobile No:
Whether Symptomatic (Yes/No)

th th th th th th
13 13 14 15 16 17
March March March March March March*

SINGATURE OF