MONITORING AND EVALUATION PLAN - TBC India

Sample identification No.:
Name of DMC to which sample is transported:
Name of referring facility:
Tool 4: Sputum collection and transportation form
(To be filled in duplicate)
Patient name: _________________________ Age: _______ Sex: M F
Complete address
Brief H/O illness
_______________________________ Date: ____________
Specimen Collectors name and Signature
© World Vision India, Axshya India Project
Monitoring and Evaluation Plan, October 2010 Page No 85