Step 1 — Select Department & Period
Choose your department — the form will automatically show only the relevant sections for your department type.
Reporting InfoDepartment, month & year
Step 2 — OPD Visits
Number of outpatient visits by age group and sex.
Step 3 — Malaria Prevention & Control
Total slides/RDT performed and positive results for malaria diagnosis by age group and sex.
Malaria DiagnosisTotal number of slides or RDT performed for malaria diagnosis — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 5 years | ||
| 5 – 14 years | ||
| ≥ 15 years |
RDT PositiveTotal number of slides or RDT positive — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 5 years | ||
| 5 – 14 years | ||
| ≥ 15 years |
Step 4 — Leishmaniasis
Visceral Leishmaniasis (VL) and Cutaneous Leishmaniasis treatment data by age, treatment type, outcome, and HIV status.
Visceral Leishmaniasis (VL)Number of VL cases treated — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 5 years | ||
| 5 – 14 years | ||
| ≥ 15 years |
VL — Treatment TypeVL patients treated by treatment type
VL — Treatment OutcomeVL patients treated by treatment outcome
VL — HIV StatusVL patients treated by HIV status
Cutaneous Leishmaniasis (CL)Number of CL cases treated — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 5 years | ||
| 5 – 14 years | ||
| ≥ 15 years |
CL — Treatment TypeCL patients treated by treatment type
CL — Treatment OutcomeCL patients treated by treatment outcome
Step 5 — NCD: Hypertension & Cardiovascular Disease
Hypertension screening, enrollment to care, 6-month cohort outcomes, and cardiovascular disease (CVD) risk data.
HTN — Screening by AgeNumber of individuals screened for hypertension by age category
| Age Group | Male | Female |
|---|---|---|
| 18 – 29 years | ||
| 30 – 39 years | ||
| 40 – 69 years | ||
| ≥ 70 years |
HTN — Screening ResultsNumber of individuals screened for hypertension by result
HTN — Enrolled to CareHypertensive patients enrolled to care by type of treatment
HTN — Enrolled by AgeHypertensive patients enrolled to care by age category
| Age Group | Male | Female |
|---|---|---|
| 18 – 29 years | ||
| 30 – 39 years | ||
| 40 – 69 years | ||
| ≥ 70 years |
HTN — Timing of EnrollmentHypertensive patients enrolled to care by timing
HTN — 6-Month CohortSix-monthly control of blood pressure among people treated for hypertension
HTN — 6-Month Cohort OutcomesTreatment outcomes for cohort registered 6 months prior
CVD — High Risk by TypeNumber of individuals in high CVD risk by type of risk category
CVD — High Risk by AgeNumber of individuals in high CVD risk by age category
| Age Group | Male | Female |
|---|---|---|
| 40 – 59 years | ||
| 60 – 74 years |
CVD — Treatment by TypePatients with high CVD risk who received treatment
CVD — Treatment by AgePatients with high CVD risk who received treatment by age category
| Age Group | Male | Female |
|---|---|---|
| 40 – 59 years | ||
| 60 – 74 years |
Step 6 — NCD: Diabetes Mellitus
Diabetes screening, enrollment to care (by type, treatment, age, timing), and 6-month cohort outcomes.
DM — Screening ResultsNumber of individuals screened for Diabetes Mellitus by result
DM — Screened by AgeTotal number of individuals screened for diabetes by age category
| Age Group | Male | Female |
|---|---|---|
| < 40 years | ||
| ≥ 40 years |
DM — Enrolled by TypeDiabetic patients enrolled to care by type of diabetes
DM — Enrolled by TreatmentDiabetic patients enrolled to care by type of treatment
DM — Enrolled by AgeDiabetic patients enrolled to care by age category
| Age Group | Male | Female |
|---|---|---|
| < 15 years | ||
| 15 – 29 years | ||
| 30 – 39 years | ||
| ≥ 40 years |
DM — Timing of EnrollmentDiabetic patients enrolled to care by timing
DM — 6-Month CohortSix-monthly control of diabetes among individuals treated for diabetes
DM — 6-Month Cohort OutcomesTreatment outcomes for cohort registered 6 months prior
Step 7 — HIV Testing Services
HIV testing results at PITC and VCT — received results and positive cases by age group, sex, and population group.
PITC — Received ResultClients receiving HIV test results at PITC — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 1 year | ||
| 1 – 4 years | ||
| 5 – 9 years | ||
| 10 – 14 years | ||
| 15 – 19 years | ||
| 20 – 24 years | ||
| 25 – 29 years | ||
| 30 – 34 years | ||
| 35 – 39 years | ||
| 40 – 44 years | ||
| 45 – 49 years | ||
| 50+ years |
PITC — PositiveClients testing positive for HIV at PITC — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 1 year | ||
| 1 – 4 years | ||
| 5 – 9 years | ||
| 10 – 14 years | ||
| 15 – 19 years | ||
| 20 – 24 years | ||
| 25 – 29 years | ||
| 30 – 34 years | ||
| 35 – 39 years | ||
| 40 – 44 years | ||
| 45 – 49 years | ||
| 50+ years |
HTS — Population Groups (PITC)HIV testing — received result & positive by population group
| Population Group | Received Result | Positive |
|---|---|---|
| Female commercial sex workers | ||
| Long distance drivers | ||
| Mobile/Daily Laborers | ||
| OVC of PLHIV | ||
| Children of PLHIV | ||
| Prisoners | ||
| Partners of PLHIV | ||
| Other MARPs | ||
| General population |
VCT — Received ResultClients receiving HIV test results at VCT — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 1 year | ||
| 1 – 4 years | ||
| 5 – 9 years | ||
| 10 – 14 years | ||
| 15 – 19 years | ||
| 20 – 24 years | ||
| 25 – 29 years | ||
| 30 – 34 years | ||
| 35 – 39 years | ||
| 40 – 44 years | ||
| 45 – 49 years | ||
| 50+ years |
VCT — PositiveClients testing positive for HIV at VCT — by age & sex
| Age Group | Male | Female |
|---|---|---|
| < 1 year | ||
| 1 – 4 years | ||
| 5 – 9 years | ||
| 10 – 14 years | ||
| 15 – 19 years | ||
| 20 – 24 years | ||
| 25 – 29 years | ||
| 30 – 34 years | ||
| 35 – 39 years | ||
| 40 – 44 years | ||
| 45 – 49 years | ||
| 50+ years |
Step 8 — Review & Submit
Review your data and submit the report. The form will be sent to Google Sheets via Apps Script.
SummaryReport summary before submission