Movement Against Malaria

FACILITY INVENTORY REPORT

Province of ______________________________________ Month of ________________________________________________

Municipality of ____________________________________ Name of Facility __________________________________________

No Commodity Unit Balance Remarks

Laboratory Supplies
1 Rapid Diagnostic Test (Combo) test
2 Rapid Diagnostic Test (Mono - Paracheck) test
3 Absorbent Cotton roll
4 Blood Lancet box
5 Buffered Salts tablet
6 Cargille Oil / Immersion Oil bottle
7 Glass Slides box
8 Isopropyl Alcohol bottle
9 Lens Paper box
10 Methanol bottle
11 Giemsa Stain (250 mL) mL
Drugs
12 Coartem 6-tablet, 5-15 kg body weight (Exp. Date: ) blister pack
13 Coartem 12-tablet, 15-25 kg body weight (Exp. Date: ) blister pack
14 Coartem 18-tablet, 25-35 kg body weight (Exp. Date: ) blister pack
15 Coartem 24-tablet, 35 kg and above body weight (Exp. Date: ) blister pack
16 Chloroquine (150 mg tablet) (Exp. Date: ) tablet
17 Primaquine (26.5 mg tablet) (Exp. Date: ) tablet
18 Quinine (Exp. Date: ) tablet
19 Quinine (Exp. Date: ) Ampule
Vector Control Commodities
20 Long lasting Insecticidal Nets (LLIN) piece
21 Indoor Residual Spraying Insecticides (IRS Insecticide) sachet
22 Mosquito Net Treatment tablet / sachet
Other Commodities
23 Cotton Dispenser piece
24 Slide Box (100 capacity) piece
25 Slide Box (25 capacity) piece
26 Slide Rack piece
27 Staining Jar piece
28 Surgical Gloves piece
29
30

Prepared by:

__________________________________________
Signature over Printed Name

Date: _____________________________________

Reviewed by:

__________________________________________
Signature over Printed Name

Date: _____________________________________