Uganda National Tuberculosis and Leprosy Programme Ministry of Health

Facility Report and Request for Drugs Republic of Uganda

Months covered: Septem/October Date compiled: _________ 11/7/2022

Facility name Amai Hospital_________________________________ Facility Code: ____________________________ Health sub-district: _____ kioga Distri

A B C D E F G H I J
Drug Pack size Opening (Quantity) Dispensed Losses or Days out of Adjusted Closing/ Months Of Quantity UNIT PER Remarks
/Beginning Received this during the 2 Adjustments* stock during AMC = Ending Stock = G/F Needed PACK SIZE
Balance Review months review the 2 (Cx30)/(60-E) Balance, = (4xF)-
Period period months Physical G
cycle Inventory
OR = (A+B-
C) +/- D

Adult formulations
RHZE 150/75/400/275 mg tablet blister of 28 tabs 192 192 0 0 0 0 384 #DIV/0! -13.7142857142857
-384
24
RH 150/75mg tablet blister of 28 tabs 48 96 48 0 0 24 96 24
0

Isoniazid 300mg tablet blister of 28 tabs 1008 0 0 0 0 0 1008 24

-1008

Rifapentine /Isoniazid 300/300 mg Pack of 36 tabs 0 0 0 0 0 0 0 0

Rifabutin 150mg capsule Box of 30 0 0 0 0 0 0 0 100

capsules 0

Pyrazinamide 400mg tablet blister of 28 tabs 0 0 0 0 0 0 15

0

Ethambutol 400mg tablet blister of 28 tabs 0 0 0 0 0 0 0 24

0

Pediatric formulations 0 0

RHZ 75/50/150mg tablet blister of 28 309 6 0 0 0 0 315 1

-315
(3 blisters) tabs
RH 75/50 mg tablet blister of 28 0 27 0 0 0 27 3
tabs
Isoniazid 100mg tablet blister of 10 tabs 0 5 15 0 10 10

Isoniazid syrup 100mg/5ml bottle 200ml bottle 0 0 0 0 0 0 1

Ethambutol 100mg tablet blister of 10 tabs 0 2 2 4 4 100

Ancillary medicines/Supplies

Pyridoxine 50mg tablet Tin of 1000 0 0 0 0 0 0 1000

tablets
0 0 0 0 0 0 20
N95 mask Piece
0 0 0 0 0 0 50
Facemasks Piece

*Explain the Losses and adjustments: ________________________________________________________________

In-charge: ____________________________________________ Signature: ____________________________Date: ____________________ Contact: _______________________

FIRST TB MEDICINES ORDER FORM

Reviewed by DTLS: _____________________________________ Signature: ____________________________Date: ____________________ Contact: _______________________

Approved by DHO: _______________________________________ Signature: ____________________________Date: ____________________ Contact: _______________________

Note: For RHZE, RH(150/75), RHZ, RH(75/50), H, E, Z Order in blisters; For Rifabutin and ancillary medicines order in packs

FIRST TB MEDICINES ORDER FORM

Amolatar

Patient Statistics

# of new adult cases

______10_______

# of child cases

_____________

# of transfers in

_____________

# Children IPT
(0 to <5years)
______________

# Children IPT
(5-14 years)
_____________

# Adult IPT

______________

FIRST TB MEDICINES ORDER FORM

DR-TB MEDICINES/SECOND LINE DRUG REQUISITION FORM (FORM12)

Health facility Name:

District:
Months covered:
Requistion no:

Date compiled:

REGIMENS Number of patients

Initiation phase Continuation

phase
No. of patients on Regimen 1:
6Km+Lfx+Eto+Cs+Z/18Lfx+Eto+Cs+Z
No. of patients on Regimen 2:
6Cm+Lfx+Eto+Cs+Z/18Lfx+Eto+Cs+Z
No. of patients on Regimen 3:
6Km+Cfz+E+Eto+H+Mfx+Z/5Cfz+E+Mfx+Z
No. of patients on Regimen 4:
6Cm+Cfz+E+Eto+H+Mfx+Z/5Cfz+E+Mfx+Z
No. of patients on Regimen 5:
6Bdq + 8Cm + Lzd + Eto +Cfz + Z / 16Lzd + Eto +Cfz + Z
No. of patients on Regimen 6:
6Bdq + 12 Lzd + Cfz + Z +Eto / 12 Lzd + Cfz + Z +Eto
Others specify:

Others specify:

Others specify:

Others specify:
 DR-TB MEDICINES/SECOND LINE DRUG REQUISITION FORM
Quantity
Daily needed Quantity on
Monthly Quantity
Item Number Item Description Unit consumption (Maximum hand (stock Quantity in packs
consumption Requested
(all patients) stock level is 4 balance)
months)
Number of packs
B=AX30(oral)
Units per pack, Requested
A C= Bx4 D E=C-D
B=Ax26 F
G = E/F
(injectables)*
155345 Kanamycin 1g vial - - - 50 -
155350 Capreomycin 1g vial - - - 1 -
215056 Amikacin 500mg vial - - - 1 -
220198 Pyrazinamide 400mg tab - - - 24 -
220204 Levofloxacin 250mg tab - - - 100 -
220205 Moxifloxacin 400mg tab - - - 100 -
220202 Cycloserine 250mg tab - - - 100 -
203010 PAS sodium granules 60% 4g sachets - - - 30 -
220203 Ethionamide250mg tab - - - 100 -
220941 Clofazimine 100mg Cap - - - 100 -
220989 Linezolid 600mg tab - - - 100 -
220888 Isoniazid 300mg tab - - - 24 -
TB-NEW1 Ethambutol 800mg tab - - - 627 -
220976 Delamanid 100mg tab - - - 672 -
220405 Pyridoxine 50mg tab - - - 100 -
220956
Levothyroxine 100micrograms tab - - - 30 -
For Bedaquiline, order for a tin of 188 tabs per patient. This is packed as a complete dose for 6 months duration for each
patient
Special
Number of patients that require Bedaquiline during the Number of tins needed (B),
reporting period (A) B=A

220917 Bedaquiline 100mg Tin of 188