Assessment of equity in provision and utilization of maternal and child health programs in butajira, southern ethiopia

Annex 2: Data collection format for health facility Record review

Identification number of the format _____/_____/_____;

Date of the review:(dd/mm/yy ___________

Name of Reviewer ___________________ : Code of Reviewer _____/______

Name of health facility ___________________ Type of health facility ___________________
NOTE TO THE REVIEWER

This is a format designed to collect data on children’s immunized for EPI during hamle 1/1995-sene 30/1996 EC in all public health institutions in Meskan and Mareko woreda, Gurage Zone. The data will be collected from children’s immunization Registers (EPI Registers) used at respective health facilities. You need to enter the only information available on the register. If the data needed is not recorded, just indicate that by (NR).

S. No	Registration No. Of immunized Child	Address of child/ Mother		Child Sex	childAge	Immunization status 1. vaccinated 2. not vaccinated
		kebele	House No.	1.M 2.F	In Months	BCG	DPT1/ OPV1	DPT2/ OPV2	DPT3/ OPV3	Measles
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