9/1-0031
(Rev. 08/00)           REPUBLIC OF NAMIBIA MINISTRY OF HEALTH AND SOCIAL SERVICES
                    Health Information System 2000  (HIS2K)
          IMMUNIZATION AND WEIGHING MONTHLY SUMMARY REPORT FORM
FACILITY NAME: ______________________     REPORT FOR: MONTH: ______________ YEAR: _______
IF THIS FORM IS FOR OUTREACH SERVICES ONLY, TICK (3) HERE:
                           
CHILDHOOD IMMUNIZATIONS   WEIGHT MONITORING
 
VACCINE/DOSE UNDER-1 1 YEAR-OLD              
YEAR-OLDS AND OLDER   0-5 6-11 12-23 24-35 36-47 48-59  
    M.O. M.O. M.O. M.O. M.O. M.O.  
BCG       --------- --------- (1 YO) (2 YO) (3 YO) (4 YO)  
             
OPV0    X X X X X X   NORMAL            
  WEIGHT………..              
OPV1                  
  MODERATE            
DPT1 (or DT1)       UNDERWEIGHT..              
             
OPV2       SEVERE            
  UNDERWEIGHT..              
DPT2 (or DT2)                    
 
OPV3       FORM COMPLETED BY:  NAME: ___________________________
 
DPT3 (or DT3)        SIGNATURE: ___________________________
 
OPV BOOSTER                  DATE: ______________
 
DT BOOSTER       FORM CHECKED BY:     NAME: ___________________________
 
MEASLES        SIGNATURE: ___________________________
 
HEPB1                  DATE: ______________
 
HEPB2                    
   
HEPB3      
 
SCHEDULE  
COMPLETE      
 
VITAMIN A      
 
WOMEN 15-49 YEARS-OLD TETANUS TOXOID  
(TT) IMMUNIZATIONS  
 
TT1    
 
TT2    
 
TT3    
 
TT4    
 
TT5