VACCINE STO

Name of Vaccine: ____________________________ Quantity Received (in vials):

Generic Name: ____________________________ Dose per vial:
Brand Name: ____________________________ Storage Location:
Manufacturer: ____________________________

Date (mm/dd/yyyy) Property Transfer Receipt No. To Whom Received/Issued

BEGINNING BALANCE
 VACCINE STOCK CARD
____________________________ Prepared by: ____________________________
____________________________ Verified by: ____________________________
____________________________

Quantity (In Vials)

Balance Qty (in dose) VVM Status
Received Issued Expiry Date Lot No.
Qty (In vials)
______________
______________

Issued/Verified by Remarks
 DILUENT STOCK C
Name of Vaccine: ____________________________ Quantity Received (in vials):
Generic Name: ____________________________ Dose per vial:
Brand Name: ____________________________ Storage Location:
Manufacturer: ____________________________

Date (mm/dd/yyyy) Property Transfer Receipt No. To Whom Received/Issued

BEGINNING BALANCE
DILUENT STOCK CARD
____________________________ Prepared by: ____________________________
____________________________ Verified by: ____________________________
____________________________

Quantity (In Vials)

Balance Qty (in dose) Issued/Verified by
Received Issued Expiry Date Lot No.
Qty (In vials)
_________
_________

Remarks
 STOCK COUNT SHEET FOR SYRINGES, SAFETY BOXES
DATE: Location:
FIRST COUNT TEAM:
SECOND COUNT TEAM:
Total Units
Count No. Item Description Pack Type Units per pack (c*d)
0
RINGES, SAFETY BOXES, AND OTHER PRODUCTS
Sheet No.:

Lot no. (Where Applicable) Expiry Date (Where applicable) Notes

 FORM 1: VACCINE USE AND WASTA
Name of Facility: Reporting Month:

Region: Date of Report:

Province: Reported by:

City/Municipality:

Barangay:

STOCK AVAILABLE FOR THE REPORTING MONTH

Total stock available for

# of vials the reporting month
returned to
Dose per # of vials higher level
Antigen vial Starting # of vials
balance (in received received or
from other transferred
vials) from DOH source* to other
health
facility # of vials
(c+d+e)-f

a b c d e f g
BCG 20 5 50 0 10 45
HepB 10 0
Pentavalent 1 0
bOPV 20 0
PCV 13 4 0
PCV 10 4 0
IPV 10 0
MMR 10 0
MMR 5
MR 10 0
Td
(Adolescent) 10 0
Td (Pregnant) 10 0
JE 5 0
HPV 1 0
PPV 1 0
Flu 10 0
 Rotavirus 1

* Number of vials received from sources other than DOH (donation, LGU procurement, etc.)
** Actual number of vials opened during immunization sessions for the reporting month
***Based on actual physical count or inventory after the last immunization session of the reporting month
ND WASTAGE MONTHLY MONITORING FO

MONTH UTILIZATION AND WASTAGE REP

otal stock available for

Vials discarded
the reporting month
# of vials
available for
routine
immunizatio
n (g-l)
# of doses # of vials # of vials # of vials Total Total
(b*g) expired with VVM damaged discarded discarded in
3/4 vials (i+j+k) doses (b*l)

h i j k l m n
900 0 0 1 1 20 44
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0

the reporting month

TORING FORM FOR VACCINATION FACILIT

TILIZATION AND WASTAGE REPORT

# of Vials Administered # of unopened vials

Wasted
# of utilized vials doses during Wastage
immunizatio Rate
n (q-o)
# of doses # of vials # of doses
administere # of opened # of doses kept at the (b*s)
d vials** (b*p) facility***

o p q r s t u
200 15 300 100 15 300
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
ON FACILITIES

INVENTORY
REPORT Remarks

Ending
Balance (in
vials) for the
reporting
month

v w
 CONSOLIDATION REPOR
Name of Facility: Reporting Month:

Region: Date of Report:

Province: Reported by:

City/Municipality:

Antigen: BCG Dose per Vial

STOCK AVAILABLE FOR THE REPORTING MONTH

Total stock available for

# of vials the reporting month
returned to
Name of Dose per # of vials higher level
Barangay vial Starting # of vials
balance (in received received or
from other transferred
vials) from DOH source* to other
health
facility # of vials
(c+d+e)-f

a b c d e f g
20 5 50 0 10 45
20 0
20 0
20 0
0
0
0
0
0
0
0
0
0
0
0

* Number of vials received from sources other than DOH (donation, LGU procurement, etc.)
** Actual number of vials opened during immunization sessions for the reporting month
***Based on actual physical count or inventory after the last immunization session of the reporting month
ON REPORT FORM 2: VACCINE USAGE AND

20

MONTH UTILIZATION AND WASTAGE REP

otal stock available for

Vials discarded
the reporting month
# of vials
available for
routine
immunizatio
n (g-l)
# of doses # of vials # of vials # of vials Total Total
(b*g) expired with VVM damaged discarded discarded in
3/4 vials (i+j+k) doses (b*l)

h i j k l m n
900 0 0 1 1 20 44
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
of the reporting month
USAGE AND WASTAGE DATABASE

TILIZATION AND WASTAGE REPORT

# of Vials Administered # of unopened vials

Wasted
# of utilized vials doses during Wastage
immunizatio Rate
n (q-o)
# of doses # of vials # of doses
administere # of opened # of doses kept at the (b*s)
d vials** (b*p) facility***

o p q r s t u
200 15 300 100 15 300
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
ASE

INVENTORY
REPORT Remarks

Ending
Balance (in
vials) for the
reporting
month

v w