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Daily Performance, FLW's Attendance and Vaccine Recording and Reporting Form 2 A
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Sheet to be filled by Area In Charge or Area Supervisor
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ProvinceDistrict Town/Tehsil/TalukaUCName of SIA:Campaign Day
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Name of AIC/ASNumber of Teams ReportedMobile/CBVFixedTransitDate
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Team #Name of Team Leader and Team MemberNumber of House HoldsTotal Children in HH from Micro PlanTotal Vaccinated
of HH Children
First Visit		Recorded Missed ChildrenCovered Missed Children
Same day Catchup		School/
MadrassaCoverage		Guest VaccinatedChildren Vaccinated in StreetsTotal HRMP Children VaccinatedVaccine Record
Doses		Finger MarkersAFP Cases NotifiedZero Dose for RI RecordedVitamin A
Capsul Used		Signature
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Target
Micro plan		Visited by teamNARNARReceivedUsedReturnedReceivedMorningEvening
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<12 M12-59 M<12 M12-59 M<12 M12-59 M<12 M12-59 M<12 M12-59 M<12 M12-59 MRedBlue
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1_______________/_______________
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2_______________/_______________
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3_______________/_______________
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4_______________/_______________
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5_______________/_______________
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6_______________/_______________
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Total
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For Fixed and Transit TeamsType of TeamTotal Vaccine RecordFinger markers issuedVerified by
Signature
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Teams TypeName of Team Leader and Team MemberNumber of Children VaccinatedVaccine Record
Doses		Finger Markers ReceivedNo. of AFP Cases NotifiedZero Dose for RI RecordedSignatureGivenUsedReturned
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ReceivedUsed
Returned
MorningEveningMobile TeamsArea In Charge / Supervisor
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_______________/_______________Fixed
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_______________/_______________TransitUC In Charge
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_______________/_______________Total
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Total
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