This form is used by direct supervisors to record the distribution activities of CRHWs on a regular basis. This form can collect data from several CRHWs in one form. The form has four sections. The first collects data on the amount and type of contraceptive distributed by CRHWs broken down by new versus old clients, as well as the number of educational talks completed by the CRHW per month broken down by sex of the participants. The second section collects information on the number and type of referrals CRHWs make, and whether those referrals were completed, or followed through on by the client. The third section notes the number and type of complications related to injections administered by CRHWs. The fourth section records the number and type of contraceptives provided to the CRHWs by the health unit.