+ +
SECTION 1 of 8: FACILITY INFORMATION
+
Facility Information
+Assessor Information
+Facility Contact Information
++ +
HOW MANY STAFF MEMBERS HAVE BEEN TRAINED IN THE FOLLOWING?
++ Clinical Staff + | ++ Total in facility + | ++ Total available on duty + | ++ Number of trained staff in IMCI + | ++ Number of trained staff in ICCM + | ++ Number of Staff Trained in Enhanced Diarrhoea Management + | ++ Number of staff trained Diarrhoea and Pneumonia CM Es for USs + | ++ How many of the total staff members trained in IMCI are still working + in Child Health Unit + | +
---|---|---|---|---|---|---|---|
+ Doctor + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ Nurse + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ R.C.O + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
HEALTH SERVICES
++ Where are sick children Seen? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ |
+
+ +
SECTION 2 of 8: GUIDELINES,JOBS AND TOOLS
+
GUIDELINES AND JOBS AIDS AVAILABILITY
++ Aspect + | ++ Response + | +|
---|---|---|
+ A. Does the facility have updated 2012 IMCI guidelines/chart booklets? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ B. Does the facility have updated ORT guidelines? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ C. Does the facility have updated Integrated Community Case Management/Community + IMCI (ICCM) guidelines? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ D. Does the facility have an updated Paediatric Protocol 2010/2013? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ E. Does the facility have an updated Diarrhoea management job aid 2014? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ F. Does the facility have updated IEC materials for categories? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ G. Does the facility have updated ART guidelines 2012? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ H. Does the facility have an updated Early Infant Diagnosis Algorithm + 2009/2012/2014? + | +
+
+
+
+ |
+
+
+
+
+ |
+
Does the unit have the following tools?
++ Aspect + | ++ Response + | +|
---|---|---|
+ A.Early Infant Diagnosis (EID) register + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ B. Under 5 Register + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ C. ORT Corner register (improvised) + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ D. Mother Child Booklet + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ E. ORT Corner register (MOH) + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ F. IMCI case recording form + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ G. Referral Slips + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ H. ICCM Tools + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 3 of 8: DOCUMENTED FACILITY LEVEL DATA
+
+ Diarrhoea Treatment in Under 5 Register + | +
+
+ 2012
+
+ |
+ |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
+ Jan + | ++ Feb + | ++ Mar + | ++ Apr + | ++ Jun + | ++ Jul + | ++ Aug + | ++ Sep + | ++ Oct + | ++ Nov + | ++ Dec + | +||
+ Total Number of Diarrhoea Cases + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS + Zinc
+ (Example: ORS+Zinc, ORS+Zinc+vitamin A, ORS+Zinc+ antibiotics, ORS+zinc+ + metronldazole + ORS+Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS
+ (Example: ORS only, ORS+ antibiotics+ ORS+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with Zinc
+ (Example: Zinc only, Zinc + antibiotic, Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with antibiotics
+ (Example:Antibiotics+other treatment without zinc or ORS, antibiotics + only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with others
+ (Example: Others+ vitamin A only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ No Treatment(i.e No drugs prescribed) | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Non Diarrhoea cases that received ORS + Zinc + | +||||||||||||
+ Fever + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Pneumonia + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Others + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Total number of cases documented in ORT Corner Register + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ Diarrhoea Treatment in Under 5 Register + | +
+
+ 2013
+
+ |
+ |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
+ Jan + | ++ Feb + | ++ Mar + | ++ Apr + | ++ Jun + | ++ Jul + | ++ Aug + | ++ Sep + | ++ Oct + | ++ Nov + | ++ Dec + | +||
+ Total Number of Diarrhoea Cases + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS + Zinc
+ (Example: ORS+Zinc, ORS+Zinc+vitamin A, ORS+Zinc+ antibiotics, ORS+zinc+ + metronldazole + ORS+Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS
+ (Example: ORS only, ORS+ antibiotics+ ORS+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with Zinc
+ (Example: Zinc only, Zinc + antibiotic, Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with antibiotics
+ (Example:Antibiotics+other treatment without zinc or ORS, antibiotics + only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with others
+ (Example: Others+ vitamin A only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ No Treatment(i.e No drugs prescribed) | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Non Diarrhoea cases that received ORS + Zinc + | +||||||||||||
+ Fever + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Pneumonia + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Others + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Total number of cases documented in ORT Corner Register + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ Diarrhoea Treatment in Under 5 Register + | +
+
+ 2014
+
+ |
+ |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
+ Jan + | ++ Feb + | ++ Mar + | ++ Apr + | ++ Jun + | ++ Jul + | ++ Aug + | ++ Sep + | ++ Oct + | ++ Nov + | ++ Dec + | +||
+ Total Number of Diarrhoea Cases + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS + Zinc
+ (Example: ORS+Zinc, ORS+Zinc+vitamin A, ORS+Zinc+ antibiotics, ORS+zinc+ + metronldazole + ORS+Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS
+ (Example: ORS only, ORS+ antibiotics+ ORS+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with Zinc
+ (Example: Zinc only, Zinc + antibiotic, Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with antibiotics
+ (Example:Antibiotics+other treatment without zinc or ORS, antibiotics + only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with others
+ (Example: Others+ vitamin A only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ No Treatment(i.e No drugs prescribed) | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Non Diarrhoea cases that received ORS + Zinc + | +||||||||||||
+ Fever + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Pneumonia + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Others + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Total number of cases documented in ORT Corner Register + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ Diarrhoea Treatment in Under 5 Register + | +
+
+ 2015
+
+ |
+ |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
+ Jan + | ++ Feb + | ++ Mar + | ++ Apr + | ++ Jun + | ++ Jul + | ++ Aug + | ++ Sep + | ++ Oct + | ++ Nov + | ++ Dec + | +||
+ Total Number of Diarrhoea Cases + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS + Zinc
+ (Example: ORS+Zinc, ORS+Zinc+vitamin A, ORS+Zinc+ antibiotics, ORS+zinc+ + metronldazole + ORS+Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with ORS
+ (Example: ORS only, ORS+ antibiotics+ ORS+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with Zinc
+ (Example: Zinc only, Zinc + antibiotic, Zinc+Others) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with antibiotics
+ (Example:Antibiotics+other treatment without zinc or ORS, antibiotics + only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Treatment with others
+ (Example: Others+ vitamin A only) |
+ + + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ No Treatment(i.e No drugs prescribed) | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Non Diarrhoea cases that received ORS + Zinc + | +||||||||||||
+ Fever + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Pneumonia + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Others + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|
+ Total number of cases documented in ORT Corner Register + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ +
SECTION 4 of 8: COMMODITY AVAILABILITY
+
MAIN SUPPLIER
++ Who is the main supplier of the commodities BELOW? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE AVAILABILITY AND MAIN REASON FOR UNAVAILABILITY FOR THE COMMODITIES + BELOW
++ Commodity Name + | ++ Commodity Unit + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Main Reason for Unavailability
+
+ |
+ |||
---|---|---|---|---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ Not Ordered
+
+ |
+
+
+ Ordered but not yet received
+
+ |
+
+
+ Expired
+
+ |
+ ||
Artemether + Leumefantrine (AL) | +20mg + 120mg | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Artesunate Injection | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Injection Quinine | +300mg/lml in 2ml amp. | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Syrup Metronidazole | +200mg/5ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Syrup Amoxicillin | +125mg/5ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Syrup Cotrimoxazole | +240mg/5ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Tablet Paed Cotrimoxazole | +120mg | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Low Osmolarity Oral Rehydration Salts (ORS) | +1 sachet (500ml) | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
RESOMAL | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Vitamin A | +50,000 IU | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Vitamin A | +100,000 IU | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Vitamin A | +200,000 IU | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Zinc Sulphate | +20mg(number of strips, 1 Strip = 10 tablets) | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
ORS & Zinc Co-pack | +4 sachets (SOOml) of ORS & 10 tablets of Zinc | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Rota Virus Vaccine | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 5 of 8: ORAL REHYDRATION THERAPY
+
ORAL REHYDRATION THERAPY CORNER ASSESSMENT
++ + *Verify this information by looking at the ORT Register and identifying + the location of the ORT Corner + + | +|||||
---|---|---|---|---|---|
+ Does this Facility have a designed location for oral rehydration? + | ++ RESPONSE + | +||||
+
+ Yes
+
+ |
+
+
+ No
+
+ |
+ ||||
+
+
+
+ |
+
+
+
+
+ |
+ ||||
+ Where is the designated location of the ORT Corner? + | +
+
+ MCH
+
+ |
+
+
+ US Clinic
+
+ |
+
+
+ OPD
+
+ |
+
+
+ Ward
+
+ |
+
+
+ Other Specify
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+ |
+ ORT Corner Functionality + | ++ RESPONSE + | +||||
+
+ Yes
+
+ |
+
+
+ No
+
+ |
+ ||||
+ (A) Are there drugs available in the ORT Corner? + | +
+
+
+
+ |
+
+
+
+
+ |
+ |||
+ (B) Is the ORT register up to date (Including zero-reporting) + | +
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 6 of 8: SUPPLIES AVAILABILITY
+
MAIN SUPPLIER
++ Who is the main supplier of the commodities BELOW? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE AVAILABILITY OF THE FOLLOWING SUPPLIES
++ Supplies Name + | +
+
+ Availability (One Selection Allowed)
+
+ |
+ |
---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+ |
Spacer | +
+
+
+
+ |
+
+
+
+
+ |
+
Suction machine | +
+
+
+
+ |
+
+
+
+
+ |
+
NG Tube | +
+
+
+
+ |
+
+
+
+
+ |
+
Disposable Syringes | +
+
+
+
+ |
+
+
+
+
+ |
+
Insulin Syringes | +
+
+
+
+ |
+
+
+
+
+ |
+
IV Starter Kit | +
+
+
+
+ |
+
+
+
+
+ |
+
Nebulizer | +
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 7 of 8: RESOURCE AVAILABILITY
+
MAIN SUPPLIER
++ Who is the main supplier of the commodities BELOW? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE AVAILABILITY AND LOCATION OF THE FOLLOWING RESOURCES
++ Resource Name + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Location of Availability (Multiple Selection Allowed)
+
+ |
+ |||||
---|---|---|---|---|---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ OPD
+
+ |
+
+
+ MCH
+
+ |
+
+
+ US Clinic
+
+ |
+
+
+ Ward
+
+ |
+
+
+ Other
+
+ |
+ |
Safe Water Source(AL) | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Electricity | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
TV | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
DVD Player | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 8 of 8: COMMUNITY STRATEGY
+
+ COMMUNITY STRATEGY + | +||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
+ ASPECT + | +
+
+ TOTAL
+
+ |
+ |||||||||||
+ (1) Total number of Community Units established and functional + | ++ + | +|||||||||||
+ (2) Total number of Community Units trained in ICCM + | ++ + | +|||||||||||
+ (3) Total number of cases treated with Zinc and ORS Co-pack under Community + Case Management of diarrhoea + | ++ + | +|||||||||||
+ (4) Total number of active CHEWS + | ++ + | +|||||||||||
+ (5) Total number of active CHEWs trained on ICCM + | ++ + | +|||||||||||
+ (6) Total number of active CHVs + | ++ + | +|||||||||||
+ (7) Total number of active CHVs trained on ICCM + | ++ + | +
To start a survey, please click begin assessmentbelow each type of survey
+To start a survey, please click 'begin assessment' below each type of survey
Select Participant + +
+Tip:
+Search either by name or facility then click the participant to begin assessment
+Participants
+Name | +Facility | +Number | +Training Site | |
---|---|---|---|---|
{{ $Participants->Name_of_Participant}} | +{{ $Participants->FacilityName}} | +{{ $Participants->mobile_Number}} | +{{ $Participants->email_address}} | +{{ $Participants->training_site}} | +
Name | +Code | +County | +Type | +Owner |
-
+
- + +
+
+ SECTION 1 of 4: FACILITY, HCW AND WORKSATION INFORMATION +
++
Facility Information
+Facility Contact Information
++ +
Assesor Information
+HCW Profile
++ +
+ + +
Work Station Profile
++ Question + | ++ Yes + | ++ No + | +
---|---|---|
1.Is the HCW still working in the original facilty they were when they + got trained? | +
+
+
+
+ |
+
+
+
+
+ |
+
If No to Question 1 indicate whether the HCW: | ++ | + |
Transfered to another facility in the same county | +
+
+
+
+ |
+
+
+
+
+ |
+
If Yes Indicate Name of facility + + | ++ | + |
Transfered to another facility in the another county | +
+
+
+
+ |
+
+
+
+
+ |
+
If Yes Indicate Name of facility + and facility + + | ++ | + |
+
+ SECTION 2 of 4: OBSERVATION OF CASE MANAGEMENT : ONE CASE PER HCW +
++
Child Profile
+Are the following Services Offered to a child?
+SERVICE | +RESPONSE | +FINDINGS | +|
---|---|---|---|
Yes | +No | ++ | |
+ (A) Temperature taken and recorded + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (B) Weight taken and recorded + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (C) Height/Length taken and recorded + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (D) Use of MCH booklet + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (E) Respitory rate taken and recorded + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (F) MUAC rate taken and recorded + | ++ + | ++ + | +
+
+
+
+
+ |
+
Are the following Danger Signs assessed in ongoing session for a child?
+SERVICE | +RESPONSE | +FINDINGS | +||
---|---|---|---|---|
Yes | +No | +Present | +Not Present | +|
+ (A) Inability to drink or breastfeed + | ++ + | ++ + | ++ + | ++ + | +
+ (B) Lethargy and Unconsciousness + | ++ + | ++ + | ++ + | ++ + | +
+ (C) Is the child vomitting everything? + | ++ + | ++ + | ++ + | ++ + | +
+ (D) Has the child had convulsions? + | ++ + | ++ + | ++ + | ++ + | +
+ (E) Is the child convulsing now? + | ++ + | ++ + | ++ + | ++ + | +
+
+ SECTION 2a of 4: ASSESSMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS +
++
Assessment of the main Symptoms in an ongoing session for a child
++ SYMPTOM + | ++ HCW RESPONSE + | ++ ASSESSOR RESPONSE + | +||||
---|---|---|---|---|---|---|
+ + 1.Cough/Difficulty Breathing + + | ++ Response + | ++ Findings + | ++ Response + | ++ Findings + | +||
Yes | +No | ++ | Yes | +No | ++ | |
+ (A) Asked how long the child had the cough + | ++ + | ++ + | ++ + + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (B) Breath counts taken and recorded + | ++ + | ++ + | ++ + + | ++ + | ++ + | +
+
+
+
+
+ |
+
+ (C) Looked for chest indrawing + | ++ + | ++ + | ++ + + | ++ + | +
+
+ + |
+ + + + | +
+ (D) Looked and listened for stridor + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (E) Looked and listened for a wheeze + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (F) Classification Done + | ++ + | ++ + | +
+
+ + + |
+ + + | ++ + | +
+
+ + + |
+
+ (F) Correct Classification + | ++ | + | + | + + | ++ + | ++ |
+ +
+ +
+ SYMPTOM + | ++ HCW RESPONSE + | ++ ASSESSOR RESPONSE + | +||||
---|---|---|---|---|---|---|
+ + 2. Diarrhoea + + | ++ Response + | ++ Findings + | ++ Response + | ++ Findings + | +||
YES | +NO | ++ | YES | +NO | +||
+ (A) Ask about the duration of diarrhoea + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (B) Ask about the prescence of blood in stool + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (C) Check if infant is lethurgic and unconscious + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (D) Check if the infant is restless and irritable + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (E) Look for sunken eyes + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (F) Perform skin pinch + | ++ + | ++ + | +
+
+ + + + + |
+ + + | ++ + | +
+
+ + + + + |
+
+ (G) Correctly assess and classify diarrhoea and dehydration + | ++ + | ++ + | +
+
+ + + + + + + + + |
+ + + | ++ + | +
+
+ + + + + + + + + |
+
+ (H) Correct Classification + | ++ | + | + | + + | ++ + | +
+ + +
+ +
+ SYMPTOM + | ++ HCW RESPONSE + | ++ ASSESSOR RESPONSE + | +||||
---|---|---|---|---|---|---|
+ + 3. Fever + + | ++ Response + | ++ Findings + | ++ Response + | ++ Findings + | +||
YES | +NO | ++ | YES | +NO | +||
+ (A) Ask about the duration + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (B) Ask about history of Travel within the past month + | ++ + | ++ + | ++ + + | ++ + | ++ + | +
+
+
+
+
+
+
+
+
+ |
+
+ (C) Temperature taken and recorded + | ++ + | ++ + | +
+
+
+
+
+ |
+ + + | ++ + | ++ + + | +
+ (D) Look for signs of measles + | ++ + | ++ + | ++ + + | ++ + | ++ + | +
+
+
+
+
+
+
+ |
+
+ (E) Malaria blood tested + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (F) If malaria test not taken, give reason + | ++ + | ++ + | +
+
+
+
+
+
+ + + + + + + +
+
+
+
+ |
+ + + | ++ + | +
+
+
+
+
+
+ + + + + + + +
+
+
+
+ |
+
+ (G) Check for neck stiffness + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +
+ (H) Classification Done + | ++ + | ++ + | +
+
+ + + + + |
+ + + | ++ + | +
+
+ + + + + |
+
+ (I) Correct Classification + | ++ | + | + | + + | ++ + | ++ |
+ + +
+ +
+ SYMPTOM + | ++ HCW RESPONSE + | ++ ASSESSOR RESPONSE + | +|||||
---|---|---|---|---|---|---|---|
+ + 4. Ear Infection + + | ++ Response + | ++ Findings + | ++ Response + | ++ Findings + | +|||
YES | +NO | ++ | YES | +NO | ++ | ||
+ (A) Ask about presence of ear pain + | ++ + | ++ + | ++ Present + + | ++ + | ++ + | ++ Present + + | +|
+ (B) Asked if there is ear discharge + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +|
+ (C) Asked for duration of discharge from ear + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +|
+ (D) Look for pus draining from ear + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +|
+ (E) Felt for tender swelling behind the ear + | ++ + | ++ + | ++ + + | ++ + | ++ + | ++ + + | +|
+ (F) Classification done + | ++ + | ++ + | ++ + + + + | ++ + | ++ + | ++ + + + + | +|
+ (G) Correct Classification + | ++ | + | + | + + | ++ + | ++ | + |
+ + +
+ +
+
+ SECTION 2b of 4: ASSESMENT FOR THE SICK YOUNG INFANT AGE UPTO 2 MONTHS(IF + APPLICABLE) +
++
+
+ 1. Very Severe Disease + | +HCW Response | +Assessor Response | +||||||
---|---|---|---|---|---|---|---|---|
+ Response + | ++ Findings + | ++ Response + | ++ Findings + | +|||||
YES | +NO | +YES | +NO | +YES | +NO | + +YES | +NO | +|
+ (A)Correct Classification + | ++ | + | + | + | + | + | + | + |
+ (B)Look For Central Cyanosis + + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (C)Look for Bulging Fontanelle + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (D)Look for pus draining from ear + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (E)Look for Skin Pustules + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (F)Asked if the infant has had convulsions + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (G)Asked and looked if the infant is able to breastfeed + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + ++ + | +
+ (H)Look if the baby is gasping or not breathing when stimulated + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | +
+ (I)Breath counts per minute + | + ++ + | + ++ + | + ++ + + | + ++ + | + + | + + + | +||
+ (J)Look for severe chest in-drawing + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (K)Look and listen for grunting + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (L)Look and listen for wheezing + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (M)Look and listen for nasal flaring + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (N)Look for red umblilicus + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (O)Look for umbilcus draining pus + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (P)Checks for fever(> 37.5C or feels hot) + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (Q)Checks Low body temperature ( <35.5C) + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ + + Checks if the Infant is drowsy(lethargic) or unconscious + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (S)Looks if the infant has no movements even when stimulated + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (T)Listen for high pitched cry + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (U)Checks for stiff neck + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (V)Correctly assesses and classifies + | + ++ + | + ++ + | + +
+ + + |
+
+ + + | + + |
+ + + |
+ ||
+ (W)Correct Classification + | + ++ + | + + | + + | + + | + + | + + | + + | + |
+ + +
+ +
+
+ 2.Jaundice + | +HCW Response | +Assessor Response | +||||||
---|---|---|---|---|---|---|---|---|
+ Response + | ++ Findings + | ++ Response + | ++ Findings + | +|||||
YES | +NO | +YES | +NO | +YES | +NO | +YES | +NO | +|
+ (A)Look for yellow discolouration of the skin including the soles + and palms + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (B)Asked for duration of the discolouration + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (C)Classification Done + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (D)Correct Classification | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + ++ + | + + ++ | +
+ + +
+ +
+
+ 3. Eye Infection + | +HCW Response | +Assessor Response | +||||||
---|---|---|---|---|---|---|---|---|
+ Response + | ++ Findings + | ++ Response + | ++ Findings + | +|||||
YES | +NO | +YES | +NO | +YES | +NO | +YES | +NO | +|
+ (A)Look for eye discharge + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | + +
+ (B)Asked for duration of eye discharge + | + ++ + | + ++ + | + ++ + + | + ++ + | + + | + + + | +||
+ (C)Asked and checked if eye is draining pus + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (D)Asked and checked if eyes are swollen + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (E)Asked snd checked if there are white spots in the pupil + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (F)Asked and looked if the infant has crossed eyes + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (G)Checked if there is clouding of the cornea + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (H)Asked and checked for fear of light + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (I)Ask and checked for fear excessive tearing + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ + | + + | + + | + ++ + | +
+ (J)Look for squeezing of the eyes + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ | + ++ + | + + | + ++ + | +
+ (K)Look for red eyes + | + ++ + | + ++ + | + ++ + | + ++ + | + ++ | + ++ + | + + | + ++ + | +
+ (L)Correctly assesses and classifies + | + ++ + | + ++ + | + +
+ + + |
+
+ + | + ++ + |
+ + + |
+ ||
+ (M)Correct classification done + | + ++ + | + ++ + | + ++ + | + ++ | + ++ + | + + | +
+ + +
+ +
+ SYMPTOM + | ++ HCW RESPONSE + | ++ ASSESSOR RESPONSE + | +||
---|---|---|---|---|
+ + 4. Diarrhoea + + | ++ Respone + | ++ Findings + | ++ Respone + | ++ Findings + | +
+ (A) Ask about the duration of diarrhoea + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+ |
+
+ (B) Ask about the prescence of blood in stool + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (C) Check if infant is lethurgic and unconscious + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (D) Check if the infant is restless and irritable + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (E) Look for sunken eyes + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (F) Perform skin pinch + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ +
+
+
+ +
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ +
+
+
+ +
+
+
+ |
+
+ (G) Correctly assess and classify diarrhoea and dehydration + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + + + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + + + + + |
+
+ (H) Correct Classification + | +
+
+
+
+ |
+ + |
+
+
+
+
+
+
+
+
+ |
+ + |
+ + +
+ +
+
+ 5A. Feeding Problem + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) Weight Taken + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (B) Weight Taken + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (C) Ask if the infant is breastfeeding + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+ (D) Ask if the infant is breastfeeding + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (E) Ask how many times the children
+ + is breastfeeding in 24hrs + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (F) Ask how many times the children
+ + is breastfeeding in 24hrs + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (G) Ask if the child is exclusively
+ + breastfeeding + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (H) Correct Classification + | ++ + | +
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+ + |
+ (I) Check for infant positioning + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (J) Check for infant positioning + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (K) Check for breast attachment + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+ (L) Check if infant is suckling effectively + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+ (M) Check for white patches or ulcers in
+ + the mouth (thrush) + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (N) Correctly assesses and classifies + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (O) Correct Classification + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+ 5B: Weight + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) Weight Taken + | +
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (B) Correctly assesses and classifies + | +
+
+
+
+
+
+
+ |
+
+
+
+
+ + + + + |
+
+
+
+
+
+ |
+
+
+
+
+ + + + + |
+
+ (C) Correct Classification + | ++ + | ++ |
+
+
+
+
+ |
+ + |
+
+ 6: Special Treatment Needs + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) Check if the mother has had fever
+ or treated for an infection with + antibiotics within two weeks after delivery + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (B) Check if the membranes were
+ raptured more than 18 hours before + delivery OR foul smelling liquor + + + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (C) Check if mother tested VDRL positive + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (D) Check if mother is confirmed HIV positive + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (E) Check if mother has been started on
+ + TB treatment in less than 2 months + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+ SECTION 3 of 4: OBSERVATION OF CASE MANAGEMENT : ONE CASE PER HCW +
++
+
+ Malnutrition + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) Checked for severe wasting + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (B) Chexked for odoema on both feet + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (C) MUAC taken and recorded + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (D) Weight taken and recorded + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+ |
+
+ (E) Malnutrition + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+ Anaemia + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) Checked for palmor pallor + | +
+
+
+
+
+
+
+ |
+
+
+
+
+ + + + + |
+
+
+
+
+
+ |
+
+
+
+
+ + + + + |
+
+ (B) Anaemia + | +
+
+
+
+
+
+
+ |
+
+
+
+
+
+ |
+
+
+
+
+
+ |
+
+
+
+
+
+ |
+
+
+
+ Condition + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) HIV exposure/infection + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (B) If child is HIV exposed, was HIV test done? + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+ (C) Immunisation Status(BCG,OPV,
+ Pentavalent,Pneumocal,Measles) + + + |
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (D) Vitamin A + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (E) Rotavirus at 6 weeks + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (F) Rotavirus at 10 Weeks + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (G) Deworming + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + |
+
+ (H) Child's feeding + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+ + + + + |
+
+ (I) Care for development + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+ (J) Other conditions + | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+ |
+
+ (K) Mother's condition + | +
+
+
+
+
+
+
+
+
+
+
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+ Treatment and Counselling + | +HCW Response | +Assessor Response | +||
---|---|---|---|---|
Response | +Findings | +Response | +Findings | +|
+ (A) Needed Vitamin A supplemenation given + | +
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+ (B) Needed Rotavirus at 6 weeks given + | +
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+ (C) Needed Rotavirus at 10 weeks given + | +
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+ (D) Needed deworming medication given + | +
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+ (E) Appropriate counselling in feeding
+ problems and homecare given + |
+
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+ (F) Appropriate follow up arranged + | +
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+ (G) Appropriate refferal done + | +
+
+
+
+
+
+
+
+
+ No
+ |
+ + + | +
+
+
+
+
+
+
+
+
+ |
+ + + | +
+
+
+ SECTION 4 of 4: CONSULTATION AND EXIT INTERVIEWS +
++
+
+ 4.1 + | ++ Consultation observation + | ++ Case 1 + | +
---|---|---|
4.1.1 | +Did provider use the IMCI Chart Booklet? | +
+
+
+
+
+
+
+
+
+
+
+ |
+
4.1.2 | +Did the provider use the under five register to document assessement & + classificaton? | +
+
+
+
+
+
+
+
+
+
+
+ |
+
4.1.3 | +Did provider inform caregiver about illness of her child? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.4 | +Did provider teach and instruct caregiver to give medicine to child? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.5 | +Did provider give first dose of medicine at health centre? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.6 | +Did provider counsel about child's feeding? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.7 | +Did provider explain how to take care of child correctly? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.8 | +Did provider ask caregiver for feedback? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.9 | +Did provider explain when to return? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.1.10 | +Did provider use caregiver's card? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
+
+
+ 4.1 + | ++ Consultation observation + | ++ Case 1 + | +
---|---|---|
4.2.1 | +Was caregiver satisfied with the service offered? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.2.2 | +Who advised caregiver to seek services at the Health Facility? | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ + + + |
+
4.2.3 | +Did caregiver explain correctly how to give medicine? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.2.4 | +Did caregiver explain correctly how to take care of child at home? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.2.5 | +Did caregiver explain when to return to health centre immediately? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.2.6 | +Did caregiver explain when to return to the health centre for follow-up? | +
+
+
+
+
+
+
+
+
+ No
+ |
+
4.2.7 | +Did caregiver explain correctly how to give medicine? | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ |
+
+
+
ASSESSMENT OUTCOME
+
+
+
+
+ |
+ + | + |
+
+
+
+ |
+ + + | +|
+
+
+
+ |
+ + + | +
+
Criteria for Certification: SECTION A
+(A) | +Correctly identifies 4 danger signs | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(B) | +Correctly identifies 4 symptoms | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(C) | +Correctly conducts HIV assessment | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(D) | +Correctly classifies, treat and counsel | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(E) | +Correct management of young infant | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+
Checked for the Following: SECTION B
+(A) | +Malnutrition | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(B) | +Anaemia | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(C) | +Deworming | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(D) | +Child's Feeding | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(E) | +Care for Development | +
+
+
+
+
+
+
+
+
+
+
+ |
+
(F) | +Immunization | +
+
+
+
+
+
+
+
+
+
+
+ |
+
+ Where NO, there are gaps identified and the HCW will need mentorship to
+ incorporate these in routine care for the child
+
If YES to all, consider HCW for TOT and Mentorship Training
+
(NOTE: IF THE HEALTHCARE WORKER FAILS TO ATTAIN ALL THE POINTS IN SECTON
+ A, THE PARTICIPANT SHOULD BE GIVEN A SECOND CHANCE. IF THE PARTICIPANT
+ FAILS IN THE SECOND ATTEMPT, MENTORSHIP IS RECOMMENDED BEFORE FURTHER ASSESMENT)
+
CERTIFICATION
+(A) | +HEALTHCARE PROVIDER CERTIFIED | +
+
+
+
+
+
+
+
+
+
+
+
+
+ |
+
(B) | +HEALTHCARE PROVIDER RECOMMENDED FOR MENTORSHIP | +
+
+
+
+
+
+
+
+
+
+
+
+
+ |
+
(C) | +HEALTHCARE PROVIDER RECOMMENDED FOR TOT | +
+
+
+
+
+
+
+
+
+
+
+
+
+ |
+
Select Facility + +
+Tip:
+Search either by name or county then click the facility to begin assessment
+Facilities
+Name | +Code | +County | +Type | +Owner |
---|---|---|---|---|
{{ $Facilities->FacilityName}} | +{{ $Facilities->FacilityCode}} | +{{ $Facilities->County}} | +{{ $Facilities->Type}} | +{{ $Facilities->Owner}} | +
Name | +Code | +County | +Type | +Owner |
-
+
- + +
+ +
SECTION 1 of 8: FACILITY INFORMATION
+
Facility Information
+Facility Contact Information
++
+
Question | +Response | +||||
---|---|---|---|---|---|
+ + | ++ + | ++ + | +
+ + |
+ ||
+ + + | ++ + + | +
+ + |
+ |||
+ + IF NO, WHAT ARE THE MAIN REASONS FOR NOT CONDUCTING DELIVERIES(multiple + selections allowed) + + |
+ |||||
+ + | ++ + | ++ + | ++ + | +
+
+
+
+ |
+ + + + | +
Question | +Response | +
---|---|
+ | + |
+ + | +
+
+
+
+ |
+
+ + | +
+
+
+
+ |
+
+ + | +
+
+
+
+ |
+
+ + | +
+
+
+
+ |
+
+ + | +
+
+
+
+ |
+
+ + | +
+
+
+
+ |
+
Question | +Response | +|
---|---|---|
+ + | ++ + | +|
+ + | +
+
+
+
+
+
+ + |
+
+
+
+
+
+
+ + |
+
+
+ +
SECTION 2 of 8: FACILITY DATA AND MATERIAL AND NEONATAL SERVICE DELIVERY
+
INDICATE THE NUMBER OF DELIVERIES CONDUCTED IN THE FACILITY IN THE PREVIOUS + YEAR(JAN-DEC)
+PROVISION OF BASIC EMERGENCY OBSTETRIC NEONATAL CARE(BEmONC) SIGNAL FUNCTIONS
+
+
+ SIGNAL FUNCTION
+
+ |
+
+
+ WAS CONDUCTED
+
+ |
+
+
+ INDICATE PRIMARY CHALLENGE
+
+ |
+ ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
+
+ YES
+
+ |
+
+
+ NO
+
+ |
+ + Inadequate Drugs + | ++ Inadequate Skills + | ++ Inadequate Supplies + | ++ No Job Aids + | ++ Inadequate Equipment + | ++ Case Never Present + | ++ No Challenged Experienced + | +||||||
+ Administration of parenternal antibiotics + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Administration of uterotonic drugs within one minute of delivery antibiotics + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Administration of uterotonic drugs within one minute of delivery antibiotics + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Manual removal of placenta + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Removal of retained products of conception + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Assisted vaginal delivery + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ New born resuscitation + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Use of partograph + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +|||||
+ Question + | ++ Response + | ++ | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
+ + | ++ + | ++ | ||||||||||||
+ + | ++ + | ++ + | ++ | |||||||||||
+ + | +
+
+ + + |
+
+
+ + + + |
+
+
+
+
+
+
+
+
+ |
+ |||||||||||
+ + | +
+
+ + + + |
+
+
+ + + + |
+
+
+
+
+
+
+
+
+ |
+ |||||||||||
+ | + + | ++ + | ++ | |||||||||||
+ + | ++ + | ++ + | ++ | |||||||||||
+ + | ++ + | ++ + | ++ | |||||||||||
+ + | ++ + | ++ + | ++ | |||||||||||
+ + | +
+
+ + + + |
+
+
+ + + + |
+
+
+ + + + |
+
+
+
+
+
+
+
+
+ |
+
+ + | ++ + | +||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
+ + | ++ + | ++ + | +|||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +||||||||||
+ + | ++ + | ++ + | ++ + | +
+ Question + | +Response | +|
---|---|---|
+ + | ++ + | +|
+ + | +
+
+ + |
+ + + | +
+
+ + |
+ + + | +|
---|---|---|
+ + | ++ + | +|
+ + | ++ + | ++ + | +
+ + | ++ + | ++ + | +
+ + | ++ + | ++ + | +
+ + | ++ + | ++ + | +
Criteria: Adult Resuscitation Kit Complete, Working and Clean ; New-born + Resuscitation Kit Complete, working and clean; Recieving Place ; Adequate + Light ; No Draft (cold air); Clean (delivery beds, recovery beds and all + surfaces); Waste Disposal System; Sterilization color-coded; Sharp Container; + Privacy, Delivery Kit Complete
+A facility must meet the ABOVE criteria to be fully prepared
+Question | +Response | +|
---|---|---|
+ + | ++ + | +|
+ + | ++ + | ++ + | +
+ +
SECTION 3 of 8: FACILITY INFORMATION
+
+ GUIDELINES AVAILABILITY + | +
+
+ RESPONSE
+
+ |
+ |
---|---|---|
+
+ Aspects
+
+ |
+
+
+ Yes
+
+ |
+
+
+ No
+
+ |
+
(1) Does the facility have updated National Roadmap to improving Maternal + and Neonatal Health | +
+
+
+
+ |
+
+
+
+
+ |
+
(2) Does the facility have updated National Guidelines for Quality Obstetric + and Essential Newborn Care? | +
+
+
+
+ |
+
+
+
+
+ |
+
(3) Does the facility have updated PMTCT guidelines? | +
+
+
+
+ |
+
+
+
+
+ |
+
(4) Does the facility have an updated Post Abortion Care Guidelines? | +
+
+
+
+ |
+
+
+
+
+ |
+
(5) Does the facility have Infant Young Child Feeding policy statement? | +
+
+
+
+ |
+
+
+
+
+ |
+
(6) Does the facility have Baby Friendly Hospital Initiative Guideline? | +
+
+
+
+ |
+
+
+
+
+ |
+
+ JOB AIDS AVAILABILITY + | +
+
+ RESPONSE
+
+ |
+ |
---|---|---|
+
+ Aspects
+
+ |
+
+
+ Yes
+
+ |
+
+
+ No
+
+ |
+
(1) Does the facility have an updated PPH (AMSTL) job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(2) Does the facility have an updated Breastfeeding job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(3) Does the facility have an updated Neonatal Resuscitation Job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(4) Does the facility have an updated MgS04 job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(5) Does the facility have an updated HBB Action Plan (Asphyxia) job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(6) Does the facility have Guidelines of Blood Transfusion in Pregnancy + job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(7) Does the facility use Methods of Oxygen Administration job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
(8) Does the facility have an updated KMC job aid? | +
+
+
+
+ |
+
+
+
+
+ |
+
+ TOOLS AVAILABILITY + | +
+
+ RESPONSE
+
+ |
+ |
---|---|---|
+
+ Aspects
+
+ |
+
+
+ Yes
+
+ |
+
+
+ No
+
+ |
+
(1) Referral Form | +
+
+
+
+ |
+
+
+
+
+ |
+
(2) CDRR (Consumption Data Request Report) | +
+
+
+
+ |
+
+
+
+
+ |
+
(3)ANC Register | +
+
+
+
+ |
+
+
+
+
+ |
+
(4) MPDSR Tools (New Born & Maternal) | +
+
+
+
+ |
+
+
+
+
+ |
+
(5) Partograph | +
+
+
+
+ |
+
+
+
+
+ |
+
(6) Maternity Register | +
+
+
+
+ |
+
+
+
+
+ |
+
(7) Post Natal Register | +
+
+
+
+ |
+
+
+
+
+ |
+
(8) Newborn Register | +
+
+
+
+ |
+
+
+
+
+ |
+
(9) Mother Child Booklet | +
+
+
+
+ |
+
+
+
+
+ |
+
(10) FP Register | +
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 4 of 8: STAFF TRAINING
+
+ HOW MANY STAFF MEMBERS HAVE BEEN TRAINED IN THE FOLLOWING? + | +|||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
+ Cinical Staff + | ++ Total in facility + | ++ Total available on duty + | ++ # of Staff Trained in Basic Emergency Obstetric Neonatal Care (BEmONC) + | ++ # of Staff Trained in Focused Antenatal Care + | ++ # of Staff Trained in Post Natal Care + | ++ # of Staff Trained in Essential Newborn Care + | ++ Maternal and Perinatal death Surveillance and review (MPDSR) + | ++ # of Staff Trained in Standards - Based Management and Recognition(SBM-R) + | ++ # of Staff Trained in Uterine Balloon Tamponade + | ++ # of Staff Trained in PP IUCD + | ++ How Many Of The Total Staff Members Trained In BEmONC are still Working + in the Maternity/ MCH / Gynaecological Ward + | +
+ Doctor + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ Nurse + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ R.C.O + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | ++ + | +
+ +
SECTION 5 of 8: COMMODITY AVAILABILITY
+
MAIN SUPPLIER
++ Who is the main supplier of the commodities BELOW? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE AVAILABILITY, MAIN REASON FOR UNAVILABILITY, DURATION OF + UNAVAILABILITY & WHAT HAPPENED WHEN THE COMMODITY WAS NOT AVAILABLE
++ Commodities + | +
+
+ Availability
+
+ (One Selection Allowed) + |
+
+
+ Main Reason for Unavailability
+
+ |
+
+
+ Duration of Unavailability
+
+ |
+
+
+ When the commodity was not available what
+
+ happened? (Multiple Selections Allowed) + |
+ |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
+ Name + | ++ + Unit + + | ++ + Available + + | ++ + Not Available + + | ++ + Not Ordered + + | ++ + Ordered but not yet received + + | ++ + Expired + + | ++ + 1 Week + + | ++ + 2 Weeks + + | ++ + 1 Month + + | ++ + More than 1 month + + | ++ + Patient purchase of the commodity privately + + | ++ + Facility purchase of the commodity privately + + | ++ + Facility received the commodity from another facility + + | +
+
+ The
+ procedure + was not + conducted + (case refered) + + |
+ + + The procedure was conducted without the commodity + + | +
Benzyl Penicillin | +5mu | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Benzyl Penicillin | +1mu | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Calcium Gluconate Injection | +100mg/ml (10%)in 10ml amp | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Ceftriaxone | +Injection 1g | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Chlorhexidine | +4% (7.1% Chlorhexidine digluconate) | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Chlorhexidine | +5% | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Dexamethasone Injection | +4mg/ml in 1ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Efavirenz (EFV) | +600MG Tab | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Emergency Oral Contraceptive | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Ergometrine | +Injection | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Female condoms | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Gentamicin | +2ml Vial 80mg/2ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Hydralazine IV | +20mg/ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
lmplanon | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Injectable Hormonal Contraceptives | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Insecticide Treated Nets | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
IUCD (Copper T) | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Jadelle | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Lamivudine/Zidovudine | +(3TC/AZT) 150MG/300MG | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Lignocaine 1% Injection | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Lopinavir+Ritonavir (LPV/r) | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Magnesium Sulphate IV | +500mg/ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Hydralazine IV | +20mg/ml | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Metronidazole IV | +500mg/100ml in 10ml amp | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Misoprostol | +200mcg | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Misoprostol | +25mcg | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Nevirapine (NVP) | +10mg/ 5ml 5yr | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Nevirapine (SD NVP) | +200MG Tab | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Oral Hormonal Contraceptives | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Oxygen | ++ |
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Oxytocin | +10 IU | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Oxytocin | +5 IU | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Sulphadoxine + Pyrimethamine | +500MG + 25MG Tab | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Vitamin K | +2mg | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Water for Injection | +10ml amp | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Zidovudine (AZT) | +300MG Tab | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 6 of 8: EQUIPMENT AVAILABILITY AND FUNCTIONALITY
+
+ Equipment Name + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Availability Quantities (In Numbers)
+
+ |
+ ||
---|---|---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ Functional
+
+ |
+
+
+ Non Functional
+
+ |
+ |
Manual/ Electrical Suction machine | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Ambu bag-Adult size | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Ambu bag-Paediatric size | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
MVA (Manual Vacuum Aspiration) kit | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Airways (different sizes) | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Patella hammer | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Large size Speculum | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Graves Vaginal Speculums | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Stethoscope | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
BP Machine | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Vacuum Pump/Extractor | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Infant Weighing Scale | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Color-coded Bins (Black, Red, Yellow) | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Adult Weighing Scale | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Fetoscope | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Resuscitaire | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Heater | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
+ Testing Supplies + | +
+
+ Availability (One Selection Allowed)
+
+ |
+ |
---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+ |
Uristicks | +
+
+
+
+ |
+
+
+
+
+ |
+
DNA PCR Testing Kit | +
+
+
+
+ |
+
+
+
+
+ |
+
Rapid Testing Kits for HIV | +
+
+
+
+ |
+
+
+
+
+ |
+
RDT strips and reagent for malaria | +
+
+
+
+ |
+
+
+
+
+ |
+
Microscope for malaria test | +
+
+
+
+ |
+
+
+
+
+ |
+
Instrument Tray | +
+
+
+
+ |
+
+
+
+
+ |
+
+ Delivery Kit Components + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Availability Quantities (In Numbers)
+
+ |
+ ||
---|---|---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ Functional
+
+ |
+
+
+ Non Functional
+
+ |
+ |
Bowls 8" | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Kidney Dish 10" | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Toothed Dissecting Forceps 6" | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Mayo Scissors curved 7" | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Cord Scissors 10cm(4") | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Needle Holder 7" | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Artery Forceps Straight 8" | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Episiotomy Scissors (Braun stadler12.5cm/Barnes 14.Scm) | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
Gallipots | +
+
+
+
+ |
+
+
+
+
+ |
+ + + | ++ + | +
MAIN SUPPLIER
++ Who is the main supplier of the commodities BELOW? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE AVAILABILITY AND MAIN REASON FOR UNAVAILABILITY FOR THE FOLLOWING KITS/SETS
++ Supplies Name + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Main Reason for Unavailability
+
+ |
+ |||
---|---|---|---|---|---|
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ Not Ordered
+
+ |
+
+
+ Ordered but not yet received
+
+ |
+
+
+ Expired
+
+ |
+ |
Delivery kit | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
IV starter kit | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Adult resuscitation kit | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Neonate resuscitation kit | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Vaginal examination pack | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Suction tube | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Cut down tray set | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Caesarian Section set | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Cord Clamps | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
Baby Wrappers I Linen (At least 3) | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 7 of 8: RESOURCE AVAILABILITY
+
INDICATE THE AVAILABILITY AND LOCATION OF THE FOLLOWING RESOURCES
++ Resource Name + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Location of Availability (Multiple Selection Allowed)
+
+ |
+
+
+ Main Source
+
+ |
+ |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Running Water | +
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ OPD
+
+ |
+
+
+ MCH
+
+ |
+
+
+ US Clinic
+
+ |
+
+
+ Maternity
+
+ |
+
+
+ Other
+
+ |
+
+
+ River/Stream
+
+ |
+
+
+ Bore-hole
+
+ |
+
+
+ Piped
+
+ |
+
+
+ Water Truck
+
+ |
+
+
+ Other
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE STORAGE AND ACCESS TO WATER
++ ASPECT + | +
+
+ Response
+
+ |
+
+
+ Specify Water Storage Point
+
+ |
+ |||||
---|---|---|---|---|---|---|---|
+
+ Yes
+
+ |
+
+
+ No
+
+ |
+ ||||||
Do you have storage of water? (if yes, Please specify) | +
+
+
+
+ |
+
+
+
+
+ |
+ |||||
Does the community have access to Water? (if yes, Please specify main + source from the selection) | ++ | + |
+
+ River/Stream
+
+ |
+
+
+ Bore-hole
+
+ |
+
+
+ Piped
+
+ |
+
+
+ Water Truck
+
+ |
+
+
+ Other
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
INDICATE THE AVAILABILITY AND STORAGE, SUPPLIER AND SOURCE OF THE FOLLOWING
++ Resource Name + | +
+
+ Availability (One Selection Allowed)
+
+ |
+
+
+ Main Supplier
+
+ |
+
+
+ Main Source
+
+ |
+ |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Electricity | +
+
+ Available
+
+ |
+
+
+ Not Available
+
+ |
+
+
+ Central Government/County Government
+
+ |
+
+
+ Privately Supplied
+
+ |
+
+
+ Own Initiative
+
+ |
+
+
+ Partner
+
+ |
+
+
+ Not Applicable
+
+ |
+
+
+ National Grid
+
+ |
+
+
+ Generator
+
+ |
+
+
+ Solar
+
+ |
+
+
+ Bio-Gas
+
+ |
+
+
+ Others
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
PROVISION FOR WASTE DISPOSAL
++ {1). How Does this facility dispose of Waste? + | +
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+
+
+
+ |
+
+ +
SECTION 8 of 8: COMMUNITY STRATEGY
+
+ COMMUNITY STRATEGY + | +||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
+ ASPECT + | +
+
+ TOTAL
+
+ |
+ |||||||||||
+ (1) Total number of Community Units attached to a facility + | ++ + | +|||||||||||
+ (2) Total number of Community Units regularly supervised and provided feedback + | ++ + | +|||||||||||
+ (3) Total number of Community Units trained on Community MNH + | ++ + | +|||||||||||
+ (4) Total number of Community Units supported with incentives for CHVs + | ++ + | +|||||||||||
+ (5) Total Number of Pregnant Cases referred by CHVs to a health facility for Skilled Birth Attendant (SBA) for the past 3 months + | ++ + | +|||||||||||
+ (6) Total Number of Infants born at home referred to the facility by CHVs + | ++ + | +|||||||||||
+ (7) Total Number of HIV Exposed Infants referred to the facility by CHVs + | ++ + | +