Vitamin Angels AnnualReporting Form - Haiti

Instructions:This report is to be completed once annually by each recipient of a Vitamin Angels grant.

Reporting should reflect data on all products granted by Vitamin Angels to your organization in one calendar year, considering any products leftover from a previous year’s report. Reporting data should capture:

1) the total doses given to all children and women at each distribution location;

2) total product losses;

3) total product remaining in inventory; and

4) complete and descriptive supporting information.

Additional Reporting Tools: Vitamin Angels highly recommends you use available government record keeping tools and reporting forms to capture distribution of VA donated products. If those resources are not available to you, additional tools are available on VA’s website ( to assist you with your recordkeeping including tally sheets, distribution registers, and a sample child health card.

Please return this completed form .

  1. General Information on Product Received by your Organization and Granted by Vitamin Angels______
  1. Date of Last Report (if applicable) (mm/dd/yy):
  2. Date of Current Report (mm/dd/yy):
  3. Organization Name:
  4. Country:

Commodity / Starting Inventory
(# doses leftover from last report) / Total # of Doses Received from VA / Total # of Doses Distributed / Total # of Doses Lost / Total # of Doses Remaining in Inventory
Example: / 10,000 / 55,000 / 58,000 / 1,000 / 5,000
Vit A 100,000 IU
Vit A 200,000 IU
Albendazole 400 mg
Multivitamins for pregnant women
  • In addition to the above table, your organization must also submit one of the following:

a)Copies of reporting forms submitted to the government that verify the total number of doses reported above (preferred), OR

b)Section B. Commodity Distribution Summary (pg. 2-3)

  • If your organization is providing copies of government forms, proceed to Section C. Commodity Distribution Details.
  • If your organization is not providing copies of government forms, you must proceed to Section B and fill out the tables and answer the questions completely.
  1. Commodity Distribution Summary______

Vitamin A/Albendazole Distribution Summary

  • Using the tables below, give distribution details of each commodity provided to your organization by Vitamin Angels. This form assumes that your organization distributesthese commodities two times per year, either during child health campaigns, or on an on-goingor routine supplementation schedule divided by "semester" (for example, every 6 months). If your organization has more than two distributions per year please copy the table below and create "Supplementation Round #3."
  • Please designate whether the organization or entity responsible for each distribution location is your organization (“my organization”) or a partner organization (“partner organization”).
  • Please record total # of doses given to the indicated beneficiary group for each distribution location.
  • Add additional lines as necessary.

Supplementation Round #1
Enter dates of distribution / Start Date (mm/dd/yy): / End Date (mm/dd/yy):
Name of Organization (My Org)
Or
Name of Organization (Partner Org) / Location Distributed
(3rd Administrative Level) / Vitamin A 100,000 IU / Vitamin A 200,000 IU / Albendazole 400 mg
DOSES to Infants 6-11 Months / DOSES to Children 12-59 Months / DOSES toNon-Target Groups / DOSES to Children 12-59 Months / DOSES to Non-Target Groups
Power of Vitamins (my org) / Commune A / 600 / 1,200 / 2,000
Children Thrive (partner org) / CommuneB / 600 / 1,200 / 2,000
TOTAL DOSES DISTRIBUTED
TOTAL LOSSES
INVENTORY REMAINING IN STOCK
Supplementation Round #2
Enter distribution dates / Start Date (mm/dd/yy): / End Date (mm/dd/yy):
Name of Organization (My Org)
Or
Name of Organization (Partner Org) / Location Distributed
(3rd Administrative Level) / Vitamin A 100,000 IU / Vitamin A 200,000 IU / Albendazole 400 mg
DOSES to Infants 6-11 Months / DOSES to Children 12-59 Months / DOSES toNon-Target Groups / DOSES to Children 12-59 Months / DOSES toNon-Target Groups
Power of Vitamins (my org) / Commune A / 600 / 1,200 / 2,000
Children Thrive (partner org) / Commune B / 600 / 1,200 / 2,000
TOTAL DOSES DISTRIBUTED
TOTAL LOSSES
INVENTORY REMAINING IN STOCK

Multivitamin Distribution Summary

  • Using the table below, give distribution details of each commodity provided to your organization by Vitamin Angels. This form assumes that your organization is distributing multivitamins throughout an entire project year.
  • Please record total # of doses given to the indicated beneficiary group for each distribution population location.
  • Add additional lines as necessary.

Enter distribution dates / Start Date (mm/dd/yy): / End Date (mm/dd/yy):
Name of Organization (My Org)
Or
Name of Organization (Partner Org) / Location Distributed
(3rd Administrative Level) / DOSES to Pregnant Women / DOSES to Breastfeeding women
(Non-Target) / DOSES to Women of child-bearing age
(Non-Target)
Power of Vitamins (my org) / Commune A
Children Thrive (partner org) / Commune A
TOTAL DOSES DISTRIBUTED
TOTAL LOSSES
INVENTORY REMAINING IN STOCK
  1. Commodity Distribution Details______

Government Reporting Details

  1. Did you share information about your distribution with the relevant government health authority (eg. Direction Sanitaire Départementale, UAS, etc.)? Yes No
  1. If yes, what is the name and title of the person to whom you reported this information?
  1. If no, please explain why:
  1. Will this data be included in government coverage and distribution reports? Yes No Unsure
  1. If no, please explain why:

Vitamin A/Albendazole Distribution Details

  1. Were the children reached during the second supplementation round the same children that were reached during the first supplementation round? Yes No

Please explain in detail:

  1. Didyou give any vitamin A or albendazole to non-target groups (i.e. beneficiaries who are not children 6-59 months)?

Yes No

If yes, how many doses did you give to non-target groups?

Why?

Multivitamin Distribution Details

  1. On average, when did you first reach pregnant women with multivitamins?

Before conception

1st trimester

2nd trimester

3rd trimester

Postpartum/breastfeeding period

Variable, please explain:

  1. On average, how many multivitamin capsules did you provide to each womanduring her pregnancy?

30

60

90

180

270

Other, describe:

  1. Did you give women’s multivitamins to non-target groups (i.e. beneficiaries who are not pregnant women)? Yes No

If yes, how many doses did you give to non-target groups?

Inventory and Loss Details

  1. If your organization is providing copies of government forms, the total quantity of doses recorded in those forms must match the reported number of doses distributed in Section A. General Information on Product Received by your Organization and Granted by Vitamin Angels. If the number does not match, please explain in detail.
  1. Do you have Vitamin Angels commodity donations remaining in stock/inventory?Yes No

If yes, list dates of product expiration and describe your distribution plan for the inventory balance.

  1. During this project, were there any product losses? Yes No

If yes, please explain any loss and attach supporting documentation as required:

In Transit (during shipment prior to receipt by the field office)

In-country Transport and/or Storage Loss

Lost in Possession of Customs & Excise

Expiration (*Please attach a certificate of destruction)

Other, please explain:

Feedback and Additional Information

  1. Is there any additional information or feedback you would like to share with Vitamin Angels? This is not required, but we are always interested to hear!

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  1. Certification of the Report______
  1. Organization Name:
  2. Contact Name:
  3. Title:
  4. Date (mm/dd/yy):

Please emaila copy of this report to:

Or fax to: +1 805-564-8499

Or mail to:

Vitamin Angels, Programs Division

PO Box 4490

Santa Barbara, CA 93140

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