DTG 50mg

available? Yes
S.N Sub city Health Facility , NO Quantity Expiry date Remark
A B C D F G H
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city
providing HIV testing have to be included (all testing corner in the facility). If yes to D,
proceed to E through H and If NO, go to the next facility. You need to use different row for
different Bach # and the unit of report has to be in the smallest unit as indicated i.e., test.
 TDF/3TC
available? Yes
S.N Sub city Health Facility , NO Quantity Expiry date Remark
A B C D F G H
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city
providing HIV testing have to be included (all testing corner in the facility). If yes to D,
proceed to E through H and If NO, go to the next facility. You need to use different row for
different Bach # and the unit of report has to be in the smallest unit as indicated i.e., test.
 INH 300mg
available? Yes
S.N Sub city Health Facility , NO Quantity Expiry date Remark
A B C D F G H
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city
providing HIV testing have to be included (all testing corner in the facility). If yes to D,
proceed to E through H and If NO, go to the next facility. You need to use different row for
different Bach # and the unit of report has to be in the smallest unit as indicated i.e., test.
 LF-LAM
available? Yes
S.N Sub city Health Facility , NO Unit Quantity Expiry date
A B C D E F G
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city providing HIV testing
have to be included (all testing corner in the facility). If yes to D, proceed to E through H and If NO, go to the
next facility. You need to use different row for different Bach # and the unit of report has to be in the smallest
unit as indicated i.e., test.
 Remark
H

ty providing HIV testing

gh H and If NO, go to the
t has to be in the smallest
 Total Quantity

RTK type (Stat

Pack, Abon,
Sub city Health Facility SD) Unit Store SDP/ Du's
A B C D E(# of tests) F(# of tests)
stat pack Tests
abon Tests
HF 1 SD Tests
stat pack Tests
abon Tests
HF 2 SD Tests
stat pack Tests
abon Tests
HF 3 SD Tests
stat pack Tests
abon Tests
HF 4 SD Tests
stat pack Tests
abon Tests
HF 5 SD Tests
stat pack Tests
abon Tests
Sub city HF 6 SD Tests

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city providing HIV testing have
included (all testing corner in the facility). All test kits has to be reported. You need to use different row for differ
# and the unit of report has to be in the smallest unit as indicated i.e., test.
 Expiry date Remark
G H

ity providing HIV testing have to be

to use different row for different Bach
 DBS kit
available? Yes
S.N Sub city Health Facility , NO Unit Quantity Expiry date
A B C D E F G
1 test
2 test
3 test
4 test
5 test
6 test
7 test
8 test
9 test
10 test
11 test
12 test
13 test
14 test
15 test
16 test
17 test

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city providing HIV
testing have to be included (all testing corner in the facility). If yes to D, proceed to E through H and If
NO, go to the next facility. You need to use different row for different Bach # and the unit of report has
to be in the smallest unit as indicated i.e., test.
 Remark
H

sub city providing HIV

d to E through H and If
nd the unit of report has
 HIVST kit
available? Yes
S.N Sub city Health Facility , NO Unit Quantity Expiry date
A B C D E F G
1 test
2 test
3 test
4 test
5 test
6 test
7 test
8 test
9 test
10 test
11 test
12 test
13 test
14 test
15 test
16 test
17 test

NB: All health facilities (Public, private, DIC and NGO clinics) under respective sub city providing HIV
testing have to be included (all testing corner in the facility). If yes to D, proceed to E through H and If
NO, go to the next facility. You need to use different row for different Bach # and the unit of report has
to be in the smallest unit as indicated i.e., test.
 Remark
H

sub city providing HIV

d to E through H and If
nd the unit of report has