FORM 3
Community/School Summary Form for Trachoma control activities implemented

State/Territory_________________________________________________________

Population Health Unit Region_____________________________________________

Community/school______________________________________________________

Date(s) of Screening ____________________________________________________

Form Completed by Name___________________________________ Date __________



Description of activity

Completeness of implementation

Intersectoral partnerships

'S'
Surgery









'A'
Antibiotics









'F'
Facial Cleanliness









'E'
Environmental conditions









Other









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