Ministry OF Health
HMIS Form 104: NTDs MDA implementation report
District ………………………………………………………………………..
Name of the facility……………………………………………………..
Subcounty ……………………………………………………………………
HMIS FORM 104: NTDS MDA IMPLEMENTATION REPORT
Health Unit _________________Level _____ Code ___ District ________________ Health Sub-district _______
Sub county____________________ reporting Period: Month _____________ Year ____________
SECTION A]: implementation units (Villages, schools/ parishes) ONCHO (River
SCHISTO (Birharzia)
targeted/covered for;- Blindness)
1. Number of villages targeted
2. Number of villages covered
3. Number of schools targeted
4. Number of schools covered
Section B] Population at risk
Under 1 year 1-4 Yrs 5-14 Yrs 15+ Yrs
M F M F M F M F Total
1. Overall total population in sub
county
Targeted Population (TP) in Sub County
2. ONCHO (River Blindness)
3. SCHISTO (Birharzia)
SECTION C]. Number of people treated in sub county with different drug packages:-
1. Treated with PZQ only
2. Treated for Oncho (IVM only)
3. Treated with PZQ +ALB/MEB only
4. Treated for LF (IVM+ALB)
5. Treated with ALB/MEB alone
6. Treated with Zith tablets or syrup
7. Treated with Tetracycline
SECTION D]. Drug accountability
Received Used Wasted Balance
IVM
PZQ
ALB
ZITH Tabs
ZITH Syrup
Tetracycline
DESCRIPTION SECTIONS
SECTION A: Villages/ parishes targeted/covered for
schisto/oncho
Fill in the number of villages and parishes, targeted and
covered for control of bilharzias or river blindness in Sub
County.
SECTION B: Population at risk in Sub County
Fill in the total number of people in Sub County and population
targeted for control of schisto and Oncho by age and sex.
SECTION C: Number of people treated in Sub County with
different drug packages
Fill in the number of people who received certain drug package in
the sub county by age and sex.
SECTION D: Drug accountability
Fill in the number of tablets or syrups received, used and
wasted for each of NTD drugs during the MDA cycle in the sub
county. The balance is auto generated
