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|
COMBINED REPORT, REQUISITION, ISSUE AND RECEIPT FORM (CRRIRF) -
Antiretroviral and
Cotrimoxazole |
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| SiteName |
{$SiteName_editcontrol}
|
 |
Data Consultant Name
{$ValidateEntry_editcontrol} |
|
Facility Code |
{$formid_editcontrol} |
Funding Source |
{$Funding_Source_editcontrol} |
| State |
{$State_editcontrol} |
Service Type |
{$Service_Type_editcontrol}
|
| Phase |
{$Phase_editcontrol} |
IPName |
{$IPName_editcontrol} |
| |
|
|
|
{END formid_label} |
|
{END formid_fieldblock}{BEGIN SiteName_fieldblock}
{BEGIN SiteName_label}
| S/No |
Drugs |
Basic Unit |
Quantity Received
during Reporting Period |
Quantity Dispensed
During Reporting Period |
Ending Balance
(Physical Count) |
Remarks |
| ARV FOR
PREGNANT MOTHERS |
| 1 |
{$Drug_1_editcontrol} |
60 tabs |
{$QtyReceived_1_editcontrol}
|
{$Qty_Dispensed_1_editcontrol} |
{$QtySOH_1_editcontrol} |
{$Remark_1_editcontrol} |
| 5 |
{$Drug_5_editcontrol} |
30 tabs |
{$QtyReceived_5_editcontrol}
|
{$Qty_Dispensed_5_editcontrol} |
{$QtySOH_5_editcontrol} |
{$Remark_5_editcontrol} |
| ARV FOR
EXPOSED BABIES |
| 17 |
{$Drug_17_editcontrol} |
30 tabs |
{$QtyReceived_17_editcontrol} |
{$Qty_Dispensed_17_editcontrol} |
{$QtySOH_17_editcontrol} |
{$Remark_17_editcontrol} |
| 18 |
{$Drug_18_editcontrol} |
25ml |
{$QtyReceived_18_editcontrol} |
{$Qty_Dispensed_18_editcontrol} |
{$QtySOH_18_editcontrol} |
{$Remark_18_editcontrol} |
| 19 |
{$Drug_19_editcontrol} |
100ml |
{$QtyReceived_19_editcontrol} |
{$Qty_Dispensed_19_editcontrol} |
{$QtySOH_19_editcontrol} |
{$Remark_19_editcontrol} |
| OPPORTUNISTICS INFECTIOUS DRUGS |
| 22 |
{$Drug_22_editcontrol} |
tabs |
{$QtyReceived_22_editcontrol} |
{$Qty_Dispensed_22_editcontrol} |
{$QtySOH_22_editcontrol} |
{$Remark_22_editcontrol} |
| 23 |
{$Drug_23_editcontrol} |
tabs |
{$QtyReceived_23_editcontrol} |
{$Qty_Dispensed_23_editcontrol} |
{$QtySOH_23_editcontrol} |
{$Remark_23_editcontrol} |
| 24 |
{$Drug_24_editcontrol} |
tabs |
{$QtyReceived_24_editcontrol} |
{$Qty_Dispensed_24_editcontrol} |
{$QtySOH_24_editcontrol} |
{$Remark_24_editcontrol} |
| OTHER
ARVS |
| 29 |
{$Drug_29_editcontrol} |
|
{$QtyReceived_29_editcontrol} |
{$Qty_Dispensed_29_editcontrol} |
{$QtySOH_29_editcontrol} |
{$Remark_29_editcontrol} |
| 30 |
{$Drug_30_editcontrol} |
|
{$QtyReceived_30_editcontrol} |
{$Qty_Dispensed_30_editcontrol} |
{$QtySOH_30_editcontrol} |
{$Remark_30_editcontrol} |
| 31 |
{$Drug_31_editcontrol} |
|
{$QtyReceived_31_editcontrol} |
{$Qty_Dispensed_31_editcontrol} |
{$QtySOH_31_editcontrol} |
{$Remark_31_editcontrol} | {END SiteName_label} |
|
{END SiteName_fieldblock}
| Please provide details (expiry dates, lot numbers
& quantities) of any
commodity that will expire in six
months time and any other
information |
| Description |
LotNo |
Expiry
Date |
Quantity |
|
{$Drug_32_editcontrol} |
{$lotNo_32_editcontrol} |
{$expirydate_32_editcontrol} |
{$Qty_expired_32_editcontrol} |
|
{$Drug_33_editcontrol} |
{$lotNo_33_editcontrol} |
{$expirydate_33_editcontrol} |
{$Qty_expired_33_editcontrol} |
|
{$Drug_34_editcontrol} |
{$lotNo_34_editcontrol} |
{$expirydate_34_editcontrol} |
{$Qty_expired_34_editcontrol} | |
|
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| {BEGIN ValidateEntry_label}{END ValidateEntry_label} |
|
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