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Annexure III.h

ICTC Code ICTC

Monthly Input Formats for Integrated Counseling and Testing Centres (ICTC)

Sections A and C common for all ICTC Clients

Section B for all clients excluding Pregnant omen

Section ! for Pregnant omen

Section " for #I$%TB colla&oration for all ICTC clients

Identification

' ame of ICTC*

+ Address*

City* Pin Code* Bloc,*

!istrict* State*

- .eporting Period* Month /ear

0 ame of 1fficer In%charge (ICTC)*

2 Contact num&er (phone)*

3 "mail Address*

4 Type of ICTC*

5 ICTC 6ocation*

Section A * Summary Ta&le * Status for the month

Total ICTC

1. Total clients registered at ANC this month 116 116

2. Number of clients provided pre-test counseling 139 116 255

3. Number of clients tested for HI 139 116 255

!. Number of Clients received results "ithin # da$s of HI test 139 116 255

%. Number of clients provided post-test counseling and given results 139 116 255

&. Number of clients diagnosed HI positive 'after 3 specified tests( 0 0 0

0 0

#.1 Number of babies tested first time under )I* 0 0

0 0

0 0

+. Number of ICTC clients referred to ,NTC 'T /icroscop$ center( 14 14

0. Number of HI infected T patients out of above 0 0

Indicator(All fields are auto%generated from other sections)ICTC Clients

'ecluding regnant"omen(

ICTC Clients -regnant"omen reastfeeding

/others

#. Total number of pregnantbreastfeeding "omen "ho are on lifelongA,T and babies "ho are initiated on s$rup Nevirapine '&"ees12

"ees(-/ air

#.2 Number of babies tested for confirmator$ test be$ond 1+ months of

age

#.3 Number of babies found HI positive out of tested 'ro" #.2( be$ond1+ months of age

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xure III.h

ICTC Code

4ection 5 rogress /ade *uring the /onth b$ the ICTC 6All cli

etails of client7s 8isit to ICTC and #I$ tests underta,en (excluding pregnant omen)Clie

Male

52

52

Number of clients received result "ithin # da$s of HI Test 52

52

9

9

ii #I$ Status of spouse;partn

$ Status of spouse;partner

iii Composition of clients undergoing #I$ test;diagnosed p

iiia Age%ise distri&uti

a Age%ise distri&utionTotal Number of client initiated Clients diagnosed HIV positive

Male Female TS;T< Total Male Female TS;T< Total

9 9 9 9 9 9 9 9

- + 9 2 9 9 9 9

-2 - 9 -5 9 9 9 9

+2 '4 9 0+ 9 9 9 9

++ '+ 9 -0 9 9 9 9

9 9 9 9 9 9 9 9al 52 -0 9 '': 9 9 9 9

iii& .oute of transmission reported &y

iii& .oute of transmission reported &y #I$ positi8e cases

tal

i8 6in,ages and referra

!epartments ; Agencies

In referral - Tested In referral - diagnose

Male Female TS/TG Total Male Female

TI ;/aternit$ Homes 9 9 9 9 9 9

Number of clients received pre-test counselinginformation

Number of clients tested for HI (.o is Bloc,ed % Auto

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ICTC Code

'ont#l( Input )orm

Section C* +aborator( Information, Consumable

1escription

$0 Total number of blood specimens from ICTC tested t#is mont#

$0i0 n( ot#er HIV tests underta.en !sentinel surveillance, etc0&

%0 Number of blood specimens found indeterminate !after 2 HIV tests&

20 Number of blood samples detected Positive in t#e first "ee. of t#e 3uarter ! 4an, pril, 4ul(, October&

20i0 Out of above number of sample sent for 5ualit( control to S+/N+

20i0a0 Out of !20i& number reported concordant

20i0b0 Out of !20i& number reported discordant

60 Number of blood samples detected Negative in t#e first "ee. of t#e 3uarter ! 4an, pril, 4ul(, October&

60i0 Out of t#e above number of sample sent for 5ualit( control to S+/N+

60i0a0 Out of !60i& number reported concordant

60i0b0 Out of !60i& number reported discordant

Consumables Name of 7it

$0 HIV test .it $!No0 of tests&

%0 HIV test .it %!No0 of tests&

20 HIV test .it 2!No0 of tests&

80 1isposable gloves pairs

ii0 Stoc. of HIV Test 7its and ot#er Consum

Opening

Stoc.

Number received

t#is mont#

No0 of Itemselocated

!Inside t#e1istrict&

60 #ole 9lood )inger Pric.Test !No0 of tests&

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;0 Condoms pieces

0 Vials

$?0 Tubes

$$0 Vacutainer

$%0 P:P 1rugs

$20 Safe 1eliver( 7its

$60 19S 7it

$80 Nevirapine Tablets

$;0 Nevirapine S(rup $?ml

$0 :faviren@ ;??mgA+amivudine 2??mgATenofovir 2??mg

%?0 +amivudine 2??mgATenofovir 2??mg

%$0 Isonia@ide 2??mg

%%0 Isonia@ide $??mg

%20 P(ridoBine 8?mg

%60 P(ridoBine %8mg

%80 Ot#ers !Specif(&

Staff t(pe

$0 Counselor 1 0

%0 +aborator( Tec#nician 1 1

Number ofpositions

sanctioned

Number ofpositions fille

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20 Staff Nurse 0 0

60 Outreac# or.ers 1 1

80 ICTC Inc#arge ' O 1 1

;0 Ot#er Staff !Specif(& 0 0

T(pe of Visit

$0 Number of visits to !)S/'S'/TG/I1& TI proDect sites/Hotspots

%0 Number of visits to .e( villages

20a Number of visits to HIV Positive General Clients

20b Number of visits to HIV Positive Pregnant omen/ 9reastfeeding mot#ers0

60 Number of visits to migrant sites/ truc.er #alting sites

80 Number of visits to ot#er NGOEs/Sta.e#olders

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for Integrated Counseling and Testing Centres !ICTC&

Staffing and Outreac# or. !ll ICTC Clients including pregnant

+aborator( Information for ICTC

Control tests Closing Stoc. 9atc# Number

0

0

0

0

0

les !Section is 9loc.ed for data entr(, please enter data ON+IN:&

No0 of Itemselocated

!Outside t#e1istrict&

:Bpired items

returned

Number

Consumed

astage /1amage !if

an(F&

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0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

iii0 Staffing 1etails

Number of staff trained during t#e mont#

Induction efres#er HIV-T9

$ 0 0 0

? 0 0 0

Number ofpositions vacant

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? 0 0 0

? 0 0 0

? 0 0 0

? 0 0 0

Out eac# ctivit( b( Counselors

No of v

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ICTC

omen&

nits

255

0

0

0

?

0

0

0

?

0

0

:Bpir( 1ate

!dd/mm/((&

5uantit(

Indented

1ate of Indent

!dd/mm/((&

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ICTC Team Training Ot#ers

0 0

0 0

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0 0

0 0

0 0

0 0

isits during t#e mont#

0

0

0

0

0

0

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CTC Code

'o

S0 No

$ Number of New ANC Registrations

% Number of regnant women ro!i"e" re#test $ounse%ing out of a%% regi

2 Number of regnant women teste" for &I'

6 4.(a) Among those "iagn

4.(b) Among those "iagn

4.($) Among those "iagn

60$ +nown &I' ,!e C%ients ("ete$te" in re!ious -ears from same ICC / f

8 Number of regnant women re$ei!e" resu%ts with in "a-s of &I' est

; Number of regnant women re$ei!e" ost#test $ounse%ing an" gi!en te