Monthly Summary Report Form: Health Center O

Facility Name: Siigaaloow Mch Type:Fixed District: B/weine Year: 202

Reporting Officer: A/lahi Galbeed Signature: Date Form c
Facility Morbidity
Disease 0 - 59 5 - 14 15+ ANC Referra GBV / FGM
m yrs yrs l

Fever case 9 16 10 0 0 Gender-based

Fever case Positiv Violence
Sexual Assault
tested for e 0 0 0
Malaria (RDT) Negati Genital
ve 9 16 10 0 0 Mutilation
Fever case Positiv Complication
Child Health
Malaria

tested for e 0 0 0 0 0
Malaria Negati OPD Curative child
(Microscopy) ve 0 0 0 0 0 new
Malaria confirmed & OPD Curative child
treated with ACT follow-up
0 0 0 0 0
Malaria confirmed & 0 0 0 Child with diarrhoea
treated with
Malaria severe 0 0 0 Child with diarrhoea
0 - 59 5+ yrs Other Conditions & dehydration
Total Child with bloody
m diarrhoea
Mental Health

Mental health Hepatitis acute (all Child with diarrhoea

disorder new 0 0 types) 0 treated with ORS
Mental health Hepatitis chronic (all and
ChildZinc
with diarrhoea
disorder types) treated with ORS
follow-up 0 0 0 only
Schistosomiasi Hypertension Child with cough
s 0 0 screening 5
Trachoma 0 0 Hypertension follow- 2 Child with pneumonia
NTD

Worm Cardiovascular (chestwith

Child indrawing &
Infestation 0 0 0 pneumonia treated
Onchocerciasis Diabetes screening with
Child antibiotics
with
0 0 0 pneumonia treated
Road Traffic Diabetes follow-up without
Child with Influenza-
Accident 0 0 0 like Illness
Knife/Gunshot 0 0 Epilepsy new 0
Snake bite 0 0 Epilepsy follow-up 0
Explosive Adverse Drug
device 0 0 Reaction 0
Medical Clinic Attendance
Emergency

emergency 0 0
 Clinic Attendance

Emergency Injury /
Trauma
0 1
Genital Discharge Headcount (all services)
4 Preventative / Promotive /
Genital Ulcer 2
Curative
STI

Other STI 0 OPD Curative new

OPD Curative follow-up
 Health Center Outpatient Services (MF-03)
weine Year: 2024 Month: December
Date Form completed: 1/1/2025
ity Morbidity
GBV / FGM 0 - 14 15 - 19 20+ yrs
yrs yrs

Gender-based 0 0 0
Violence
Sexual Assault
0 0 0
Genital
Mutilation 0 0 0
Complication
Child Health 0 - 59 5 - 9 yrs
m
OPD Curative child
new 26 103
OPD Curative child
follow-up
4 22
Child with diarrhoea 12 5
Child with diarrhoea 0 0
& dehydration
Child with bloody
diarrhoea 0 2
Child with diarrhoea
treated with ORS 12 5
and Zinc
Child with diarrhoea
treated with ORS
only 0 0
Child with cough
5 34
Child with pneumonia 4 1
(chestwith
Child indrawing &
pneumonia treated 4 1
with
Child antibiotics
with
pneumonia treated 0 0
without antibiotics
Child with Influenza-
like Illness 3 47

0 - 59 5+ yrs
months
 Mal Female Male Female
e

10 20 41 84

8 18 33 70
2 2 8 14
 Monthly Summary Report Form: Immunisation & Child Health S
06)Name: Siigaaloow Mch
Facility / Type: Fixed District: Beled-weyne Year: 2024
Reporting Officer: A/lahi Galbeed Signature: Date Form completed: 1/1/202
Immunisation 0-11 m 12-59 m Infant,Young Child Feeding 6-11 m
(Refer to Facilit Outreach / Facility Outreach / (IYCF) & Micronutrient Facility
Immunisation y Mobile Mobile Supplementation
Register)
BCG (Bacillus Vitamin A Supplement (6 -
Calmete-Guerin) 14 0 11 m) 100,000 IU (Blue)
0
OPV 0 dose (Oral
Polio Vaccine) 12 0
OPV 1st dose 14 0 0 0 Vitamin A supplement
OPV 2nd dose (12 - 59 m) 200,000 IU
33 0 0 0
(Red)
OPV 3rd dose 19 0 0 0 Deworming (12 - 59 0
Pentavalent 1st months) Facility
dose 14 0
Pentavalent 2nd MMN Powder (6 - 23
dose 33 0 0 0 months) 0
Pentavalent 3rd
dose 19 0 0 0
IPV 1st dose 19 0 0 0 0
IPV 2nd dose 0 0 0 0 Sessions planned
PCV 1st dose Sessions conducted
(Pneumococcal Vaccine)
0 0
PCV 2nd dose 0 0 0 0 Days refrigerator temperature went
PCV 3rd dose 0 0 0 0 out of normal range (during
calendar month)
Rotavirus 1st dose 0 0
MR 1st dose
(Measles / Rubella 16 0 0
Vaccine) 0
MR 2nd dos
(Measles / Rubella 0 0
Vaccine)
Adverse Event Outreach includes Mobile services
Following
Immunisation (AEFI) 0 0 19 0
Case
0-5m 6 - 11 m 12 - 59 m
Nutrition Facilit Outreach / Facility Outreach / Facility Outreach /
Assessment y Mobile Mobile Mobile

Child screened Children screened Weight for Heigh

Weight for Height 0 0 0 0 0
Weight for Height -2
SD and above
(normal) 0 0 0 0 0
Weight for Height -2
to -3 SD
(moderate) 0 0 0 0 0
Weight for Height
below -3 SD
(severe) 0 0 0 0 0
Child screened Children screened for MUAC Red/Ye
MUAC 0 0 0 30 0 screened
MUAC Red 0 0 4 0
MUAC Yellow 0 0 5 0
MUAC Green 0 0 21 0
Nutritional Bilateral
Oedema 0 0 0 0 0
Integrated Weight for height MUAC Odema
Management of Acute 0 - 5 m 6 - 11 m 12 - 59 m 6 - 11 m 12 - 59 m 0 - 5 m 6 - 11 m 12 - 59 m
Malnutrition (IMAM)
Child identified
with SAM 0 0 0 0 4 0 0
Child identified
with MAM 0 0 0 0 5 0 0
Beginning of Month New Admission
Therapeutic or 6 - 11 m 12 - 59 m 6 - 11 m 12 - 59 m
Feeding M F M F M F M F
Programmes

Outpatient
Therapeutic 0 0 0 0 0 0 1 3
Program (OTP)
Supplementary
Feeding Program 0 0 0 0 0 0 0 0
(SFP)
Stablisation Centre
(SC) 0 0 0 0 0 0 0 0
Outcomes Cured Defaulter Death Non-Responder Internal Transfer /
Referral
Outpatient
Therapeutic 0 0 0 0 0
Program (OTP)
Supplementary
Feeding Program 0 0 0 0 0
(SFP)
Stablisation Centre
(SC) 0 0 0 0 0
COVID 1st Dose 2nd Dose Booster / Other
Vaccination Male Female Male Female Male Female
Point-of-entry Staff 0 0 0 0 0 0
Police 0 0 0 0 0 0
Municipality Staff 0 0 0 0 0 0
Health Workers 0 0 0 0 0 0
Population 50+
years 0 0 0 0 0 0
Teacher 0 0 0 0 0 0 Complied by
Others (People Signature
vaccinated not
included in
above categories) 0 0 0 0 0 0
& Child Health Services Hospitals & HCs (MF-
Year: 2024 Month: December
e Form completed: 1/1/2025
6-11 m 12-59 m
Outreach / Facility Outreach /
Mobile Mobile

19

0 13 0
Facility Outreach / Mobile

0 0

0
Several alarms during the day count as one day.
0 Value must be between
0 - 30 / 31 days.

services

screened Weight for Height must be the sum of of the 3 categories

 screened for MUAC Red/Yellow/Green must equal the sum of MUAC
d
 Monthly Summary Report Form: Maternal & Reproducti
08)Name: Siigaaloow Mch
Facility / Type: Fixed District: Beled-weyne Y
Reporting Officer: A/lahi Galbeed Signature:
Antenatal Care (Refer to ANC Method of Delivery IN Health Facil
Register) Facili Outreac
ty h/
Mobile
ANC 1st visit Delivery normal
15 0
ANC 1st visit under 12 Delivery Assisted Vaginal (Instrumental /
weeks 4 0 Ventouse)
ANC 1st visit Delivery Caesarean Section
Haemoglobin tested 0 0
ANC 1st visit urine Delivery in Facility
tested 0 0
ANC 1st visit blood Delivery by SBA
pressure taken (Doctor, Midwife, Nurse
Midwife)
15 0
15
ANC 1st visit
screened for Syphilis

0 0
ANC 2nd visit 8 0 Delivery by other cadres
8
ANC 3rd visit 3 0 (CHW, Auxiliary Midwife,
ANC 4th visit etc.)
Delivery monitored with
0 0 23
ANC 5th+ visit 0 0 Partograph
Uterotonic prophylactic
0
ANC LLIN given 0 0 given
ANC Deworming immediately after(Refer
Postnatal Care delivery
to PNC register)
medication
3 0
ANC Micronutrient
supplementation
0 0
ANC Iron Folic Acid 1st Postnatal 1st visit (0-48 hrs)
supply
15 0
ANC Iron Folic Acid 2nd Postnatal 1st visit (48+ hrs)
supply
8 0
ANC Iron Folic Acid 3+ Postnatal 2nd+ visit
supply 4 0
ANC IPTp 1st dose Postnatal mother given Iron
0 0
supplement
ANC IPTp 2nd dose Postnatal mother given Micronutrient
supplementation
0 0
ANC IPTp 3rd dose Postnatal mother given IYCF
0 0 Counselling
ANC IYCF Counselling 40 0
Birth Spacing Services (Refer Birth Td
Spacing Register)
Method New Continu Comm (Refer EPI
Client ing odities Register)
Client

Implants 0 0 0 Td 1st dose

Oral Contraceptives 0 0 0 Td 2nd dose
Injectables (Depo) 0 0 0 Td 3rd dose
IUDs 0 0 0 Td 4th dose
Condoms Female 0 0 0 Td 5+ dose
Condoms Male 0 0 0
Emergency Obstetric Care
Pregnancy induced Hypertension (Eclampsia) treated with IV 0
Anticonvulsants
Manual removal of placenta 0
Antibiotics IV for Sepsis 0
Uterotonics IV for Bleeding 0
Newborn Resuscitation 0
Blood transfusion during delivery 0
Pregnancy / Delivery Related Complications

Pregnancy induced Hypertension / Proteinuria (Pre-eclamsia) 0

Pregnancy induced seizures (Eclampsia) 0
Haemorrage antepartum 0
Haemorrage postpartum 0
Sepsis
Complications obstetric (obstructed labour / placenta abruption / 0
Complications non-obstetric (severe anaemia not due to 0
Complications foetal (nuchal cord / perinatal asphyxia / mechanical 0
Miscarriage / Spontaneous Abortion / Termination of 0
 al & Reproductive Services Hospitals & HCs (MF-
ict: Beled-weyne Year: 2024 Month: December
Date Form completed: 1/12/2025
Delivery IN Health Facility (Refer to Delivery Register)
10-14 15-19 20-24 25+ yrs
yrs yrs yrs

0 1 7 15
Instrumental /
0 0 0 0

0 0 0 0
Outcome of Facility Deliveries / Births

Live Birth in facility

23
Still Birth fresh in facility

0
Still Birth macerated in 0
facility
Live Birth Weight under 0
2.5 kg
Live Birth <= 36 Weeks 0
Gestation
Breastfed within 1 hour 23
of Birth Death early (0-7
Neonatal 0
days)
PNC register) Mother Neonate

Facili Outrea Facili Outreach

ty ch ty

hrs)

22 0 0 0
hrs)
21 0 0 0

19 0 0 0
ron
31 0 0 0
Micronutrient
31 0
YCF
43 0

Td Antenatal WCBA /
Non-Pregnant
Refer EPI Facili Outrea Facili Outreach
Register) ty ch ty

t dose 5 0 0 0
d dose 2 0 0 0
d dose 4 0 0 0
h dose 3 0 0 0
+ dose 2 0 0 0

PLW (Pregnant & Lactating Women)

MUAC screened ANC 48
MUAC screened PNC 62
PLW admitted into 0
PLW admitted 0

Maternal Death in Facility

10- 15-19 20- 25+ yrs
14 yrs 24
yrs yrs
0 0 0 0