Central/District Warehouse
Facility #____ (1-5)

Indicators:

% of expired drugs

Availability of key drugs

Facility ______________________

Date __________________________

Location _____________________

Investigator ____________________

Key drugs to treat common conditions [A]

Drugs in stock
[B]
Yes=1, No=0

Drugs in stock that have expired
[C] Yes=1, No=0

1. Amoxicillin capsules 250mg

2. Acetylsalicylic acid (aspirin) tablets 300mg

3. Chloroquine tablets 150mg base

4. Cotrimoxazole tablets 480mg

5. Ferrous sulphate + folic acid tablets 200mg/400mcg

6. Mebendazole tablets 100mg

7. Metronidazole tablets 200mg

8. Retinol (vitamin A) capsule (drops) 100,000 IU

9. Sulphadoxine/pyrimethamine tablets 500/25mg

10. Benzylpenicillin injection 1g (1MU)

11. Gentamicin injection 40mg/mL

12. Hydralazine injection 20mg/mL

13. Magnesium sulphate injection 50%

14. Measles vaccine

15. Medroxyprogesterone injection 150mg/mL

16. Methylergometrine injection 200mcg/mL

17. Benzoic acid + salicylic acid ointment 6% + 3%

18. Paracetamol syrup 120mg/5mL

19. Oral Rehydration Salts (ORS)

20. Tetracycline eye ointment 1%

Total no. of key drugs [A¹] =

[B¹] =

[C¹] =

% drugs in stock [B²] =

% drugs expired [C²] =

[A]

List of 20 key drugs previously identified at national level must be printed before starting the survey. The process is described on page 21. Add the total number of key drugs [A¹].

[B]

Mark 1 if stock is available (even if only one dosage form is available). Mark 0 if the drug is not physically available. Add the total at the bottom [B¹].

[B²]

[C]

For all drugs in stock, check if expired or not. If any of the strengths has an expiry problem, the answer for the drug should be “Yes”. Add all the “Yes” answers = [C¹]

[C²]