Annex X: Antimalarial Medicines Dispensing Register

Name of the Health Institution: _________________________________ Month:___________________ Year:__________________________

Serial Number

Date (DD/MM/YY) E.C

Card Number

Weight (Kg)

Type of visit
Sex Age Diagnosis Quantity of AMM dispensed

Female

Male

3month - 2 yrs

3 – 7 years

8 – 10 years

m
P.falciparu

P.vivax

M ixed

Other

AL 1x6 (strips)

AL 2x6 (strips)

AL 3x6 (strips)

AL 4x6 (strips)

Artesunate injection (vials)

Chloroquine 150 mg tab

(bottle)
Chloroquine 50mg/5ml Syrup

Primaquine 7.5mg tablet

>10 years

Quinine 300/600mg tablet

Patient’s Nam e

Pregnant

Non -pregnant

Regular

Referral

Uncomplicated

severe
1 1-Jan-17 12B NV123 Chala Haro ✓ ✓ ✓ ✓ 1 ¾
2 1-Jan-17 12B NV124 Hago s Girmay ✓ ✓ ✓ ✓ 1 1
3 3-Jan-17 12B NV125 Zemedkun Tase ✓ ✓ ✓ ✓ 1 0
4 4-Jan-17 12B NV126 Chalachew Yigletu ✓ ✓ ✓ ✓ 1 2 ½
5 5-Jan-17 12B NV127 Tesema Taye ✓ ✓ ✓ ✓ 1 1
6 6-Jan-17 12B NV128 Helen Tase ✓ (2months) ✓ ✓ ✓ 1
7 7-Jan-17 12B NV129 M ahlet Tache ✓ ✓ ✓ ✓ 10
8 7-Jan-17 12B NV130 Dinkinsh Tefera ✓ ✓ ✓ ✓ 1 2
9 7-Jan-17 12B NV131 Helen M akuanint ✓(7months) ✓ ✓ ✓ 1 4 2
10 10-Jan-17 12B NV132 Taye Dandi ✓ ✓ ✓ ✓ 1 10 2
11 11-Jan-17 12B NV133 To la Guracha ✓ ✓ ✓ ✓ 1 2
12 12-Jan-17 12B NV134 Chung Dagne ✓ ✓ ✓ ✓ 1 2
13 13-Jan-17 12B NV135 Hirut Taye ✓ ✓ ✓ ✓ 1 2
14 14-Jan-17 12B NV136 Rahel B o nsa ✓ ✓ ✓ ✓ 1 2
15 15-Jan-17 12B NV137 Ketema Lema ✓ ✓ ✓ ✓ 1 ¾
16 16-Jan-17 12B NV138 Lema Derese ✓ ✓ ✓ ✓ 1 1
17 17-Jan-17 12B NV139 Yinenbeb Raeiyu ✓ ✓ ✓ ✓ 1 ¾
18 17-Jan-17 12B NV140 Darge B erhan ✓ ✓ ✓ ✓ 1 2
19 17-Jan-17 12B NV141 Yihun Gizew ✓ ✓ ✓ ✓ 1 ½
20 17-Jan-17 12B NV142 Sifan To lera ✓ 17 ✓ ✓ 10
21 21-Jan-17 12B NV143 P awlo s Ujulu ✓ 46 ✓ ✓ 10
22 22-Jan-17 12B NV144 A safw M arko s ✓ 32 ✓ ✓ 10
23 22-Jan-17 12B NV145 Eskel Yo hanis ✓ 8 ✓ ✓ 3
24 22-Jan-17 12B NV146 M o hammed Oumer ✓ 4 ✓ ✓ 1
25 25-Jan-17 12B NV147 Tesfaye Yo sef ✓ ✓ ✓ ✓ 1 ½
26 25-Jan-17 12B NV148 Imanu Hassen ✓ ✓ ✓ ✓ 1 1
27 25-Jan-17 12B NV149 Wo rku M o hammed ✓ ✓ ✓ ✓ 1 1
28 28-Jan-17 12B NV150 Husen A bdella ✓ ✓ ✓ ✓ 1 ¾
29 29-Jan-17 12B NV151 Seble A bebe ✓ ✓ ✓ ✓ 4
Total

Count
Sum (consumption)
Annex XX: Data collection form for evaluation of health facility level quarterly national malaria treatment guidelines adherence

Table----. Health facility level Quarterly national malaria

treatment guidelines adherence
Number of
Malaria cases %
patients/cases
Malaria (clinical without
laboratory confirmation)
Malaria (confirmed with P.
falciparum)
Malaria (confirmed with species
other than P. falciparum)
Total

HMIS Morbidity and Mortality in IPD

Morbidity in OPD Mortality in OPD
Male Female Male Female
0-4 14-May >=15 0-4 14-May >=15 0-4 14-May >=15 0-4 14-May
Disease
years years years years years years years years years years years
Priority infectious diseases
Epidemic prone diseases
Malaria (clinical without laboratory
28 22 42 22 16 33 0 0 0 0 0 0
confirmation) q’ly total
month 1 9 8 17 8 6 12 0 0 0 0 0 0

month 2 0 0 0 0 0 0
9 6 8 6 4 9
month 3 10 8 17 8 6 12 0 0 0 0 0 0
Malaria (confirmed with P. falciparum)
27 21 42 20 15 31 0 0 0 0 0 0
q’ly total
month 1 10 8 17 8 6 12 0 0 0 0 0 0
month 2 9 7 14 7 5 10 0 0 0 0 0 0
month 3 8 6 11 5 4 9 0 0 0 0 0 0
Malaria (confirmed with species other
24 19 37 18 13 27 0 0 0 0 0 0
than P. falciparum) q’ly total
month 1 8 6 11 5 4 9 0 0 0 0 0 0
month 2 7 6 12 6 4 8 0 0 0 0 0 0
month 3 9 7 14 7 5 10 0 0 0 0 0 0
 Annex XX : DUE criteria and data collection form for Uncomlicated case p.F malaria case management
Table__________: DUE Criteria (indicators) for Uncomlicated case p.F malaria case management
Medicine Prescribed AL+PQ
Age category 3 months - 2 yrs 3 - 7 yrs 8 - 10 yrs >10 yrs
2tabs AL + single 3tabs AL+ single 4tabs AL + single
Dose 1tab AL + single dose PQ dose PQ dose PQ dose PQ
Frequency Twice a day Twice a day Twice a day Twice a day
Duration 3 days 3 days 3 days 3 days

Table_____. Data collection form for Uncomlicated case p.F malaria case management

Age category
Patient
encounter
#
Medicine
3 months - 2 yrs 3 - 7 yrs 8 - 10 yrs >10 yrs Prescribed Dose Frequency Duration

Total
Count
%
 Annex XXXXX: DUE criteria and data collection form for Uncomlicated case p.F malaria case
management in preganant mothrers in 1st trimester
Table_____: DUE Criteria Uncomlicated case p.F malaria case
management in preganant mothrers in 1st trimester

Medicine Prescribed Quinine tablet

Dose 2 tabs
Frequency Three times per day

Duration 7 days
Table____: Data collection form for Uncomlicated case p.F malaria case
management in preganant mothrers in 1st trimester

Age category
Patient
encounter
#
Medicine
>10 yrs Prescribed Dose Frequency Duration

Total
Count
%
 Annex XXXXXX: DUE criteria and data collection form for Uncomlicated mixed case
malaria management

Table ___: Criteria for Uncomlicated mixed case malaria management

Medicine Prescribed AL+PQ
Age 3 months - 2 yrs 3 - 7 yrs 8 - 10 yrs >10 yrs
1tab AL + single 2tabs AL + 3tabs AL+ 4tabs AL +
Dose dose PQ single dose PQ single dose PQ single dose PQ
Frequency Twice a day Twice a day Twice a day Twice a day
Duration 3 days 3 days 3 days 3 days

Table____: Data collection form for Uncomlicated mixed case malaria management

Patient Medicine
encounter # 3 months - 2 yrs 3 - 7 yrs 8 - 10 yrs >10 yrs Prescribed Dose FrequencyDuration

Total Count
%
 Annex XXX: DUE criteria and data collection form for Uncomlicated case p.V malaria case management with Chloroquine

Table______: Criteria for Uncomlicated case p.V malaria case management with Chloroquine
Medicine Chloroquine
prescribed

Age
4 – 11 months 1 – 2 years 3 – 4 years 5 – 7 years 8-11 yr 12-14 yr 15 yr + adult
Day 1 ½ tablet or 7.5 ml syrup 1 tablet or 12.5 ml syrup 1 tablet or 15 ml syrup 1 ½ tablets or 20 ml syrup 2 ½ tablets 3 tablets 4 tablets
Dose Day 2 ½ tablet or 7.5 ml syrup 0.5 tablet or 12.5 ml syrup 1 tablet or 15 ml syrup 1 ½ tablets or 20 ml syrup 2 tablets 2 tablets 4 tablets
Day 3 ½ tablet or 5 ml syrup 0.5 tablet or 7.5 ml syrup 1 tablet or 15 ml syrup 1 tablet or 15 ml syrup 1 tablet 2 tablets 2 tablets
once per
Frequency
once per day once per day once per day once per day once per day once per dayonce per day once per dayday once per day
once per day
Duration 3 days 3 days 3 days 3 days 3 days 3 days 3 days 3 days 3 days 3 days 3 days

Table____: Data collection form for Uncomlicated case p.V malaria case management with Chloroquine

Age category

Patient
encounter #

4 – 11 Medicine
months 1 – 2 years 3 – 4 years 5 – 7 years 8-11 yr 12-14 yr 15 yr + adult Prescribed Dose Frequency Duration

Total Count
%
Annex XXXX: DUE criteria and data collection form for Treatment for severe malaria

Table______:Criteria for Treatment for severe malaria

Medicine
Prescribed Artesunate inj

Dose 3 mg/kg

Frequency & On admission (time = 0), then at 12h and 24h, then
Duration daily for up to five days
Note: Once a patient has received at least 24 h of parenteral therapy
and can tolerate oral therapy, the treatment should be completed
with 3 days full dose of an AL based on the age of the patient. Thus,
adherence to standard treatment should be evaluated accordingly.

Table____: Data collection form for Treatment for severe malaria

Age category

Patient
encounter #

3 months - 2 Medicine
yrs 3 - 7 yrs 8 - 10 yrs >10 yrs Prescribed Dose Frequency Duration

Total Count
%