Child pages
  • Paper forms for SCI ETC

COMPLETE FORM IN DISCHARGE TENT UPON DISCHARGE FROM ETC

Name: Surname ______________________ Given name _______________________

 

Mobile # _________________________    2 nd mobile # _________________________

 

Where is the patient going now:    House#/Street (if any) ______________________

    District ______________________   Chiefdom/Ward _____________________

    Town/village __________________         

 

Mode of transportation :   Save the children vehicle    Taxi     Family    Other       

Is the patient accompanied by SC staff:     YES     NO     

      If yes,     Name of the accompanying person: ______________________________

      If no, reason : ________________________________________________________

                               _________________________________________________________

 

Discharge package

Solidarity kit provided?   YES   NO               

Hygiene kit provided?      YES     NO 

Food ration provided?     YES    NO     

Condoms provided?          YES     NO   

Cash provided (Le 750,000)?               YES     NO   

Certificate of discharge provided?   YES     NO   

 

Form completed by (print name): _______________________________________

 

Signature:  __________________________________________________________