Learner's Guide - Global Alliance to Eliminate Lymphatic Filariasis

Annex 1
Pro-forma for recording household
members for mass drug administration
1. State/Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Implementation Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Autonomous Community/Village . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Ward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Household identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Details of household members and history of receiving ivermectin and albendazole
S. Name Relation to head of household Age Sex Treatment Date Number
No. (surname/family name) (years) (m/f) received (y/n) received of
reasons for not tablets
taking (code*) (S/L) @
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Note: List should include all the members of the household even if they did not receive or refused the drugs
* Code for reasons for not taking drugs: 1-Pregnant; 2-Lactating; 3-Sick; 4-No knowledge; 5-Not present; 6-Did not receive; 9-Others
@ S- small tablets (ivermectin) L-large tablets (albendazole)
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