EPI VACCINES ORDER FORM

EPI VACCINES

A B C D E

QTY. RECEIVED ISSUANCES

( E ) ( A+B) (C+D)

BCG, 2O DOSE 0BCG DILUENT 0POLIO, 20 DOSE 0POLIO DROPPER 0HEPA B, 1 DOSE 0TET. TOX., 20 DOSE 0MEASLES, 10 DOSE 0MEASLES DILUENT 0MMR, 5 DOSE 0MMR DILUENT 0PENTA, 1 DOSE 0PCV, 1 DOSE 0ROTA, 1 DOSE 0

PREPARED BY:MARBELYN DIWATA. A CAPA RM

BRGY HEALTH MIDWIFE

FORMULABCG TP X TARGET (2.7%) X NO. DOSE (1) X WASTAGE FACTOR (2.50) / 20 / 4

POLIO TP X TARGET (2.7%) X NO. DOSE (3) X WASTAGE FACTOR (1.67) / 20 / 4HEPA B TP X TARGET (2.7%) X NO. DOSE (1) X WASTAGE FACTOR ( 1.10) / 1 / 4

TT TP X TARGET (2.7%) X NO. DOSE (2) X WASTAGE FACTOR (1.67) / 20 / 4MEASLES TP X TARGET (2.7%) X NO. DOSE (1) X WASTAGE FACTOR (2.00) / 10 / 4

MMR TP X TARGET (2.7%) X NO. DOSE (1) X WASTAGE FACTOR (1.10) / 5 / 4PENTA TP X TARGET (2.7%) X NO. DOSE (3) X WASTAGE FACTOR (1.10) / 1 / 4

PCV TP X TARGET (2.7%) X NO. DOSE (3) X WASTAGE FACTOR (1.1) / 4

AS OF 3RD QUARTER OF 2015

TOTAL POPULATION: 7292

MUNICIPALITY: TANAY DATE: _________________

BHS / BARANGAY: BRGY. WAWA BHS ELIGIBLE POP. 197

PREVIOUS QUARTER STOCK VALUE

ADJUSTMENT DAMAGED, EXPIRED,

LOSS, ETC.

CURRENT STOCK AVAILABLE

EPI VACCINES ORDER FORM

F G H I

BUFFER STOCKREMARKS

SEE FORMULA BELOW ONE MONTH F+G H-E

6 2 8 86 2 8 8

12 4 16 1612 4 16 1654 18 72 728 3 11 11

10 3 13 1310 3 13 1311 3 14 1411 3 14 14

163 54 217 217163 54 217 217

0 0

CHECKED BY:NORMA M. GALENO RNPUBLIC HEALTH NURSE

NOTED BY:RENE V. LUCE, MD

MUNICIPAL HEALTH OFFICER

QUARTER OF 2015

7292

DATE: _________________

ELIGIBLE POP. 197

QRTR REQUIREMENT PER POPULATION

AUTHORIZED STOCK LEVEL

REQUEST / ORDER TOTAL REQUIREMENT