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Staff Nurse Template 2 -Form Fill

Identification
Q01

Serial number
Q02

District name
Q03

District code
Q04

Block name
Q05

Block code
Q06

Health Facility name
Q07

Health Facility code
Q08

Type of Health Facility
Q09

Date of interview (DD/MM/YYYY)
Q10

Start time of interview

Q11

End time of interview
Q12

Name of the interviewer
Q13

Name of the supervisor
Q14

Interview Result
Background Information
A01

Name of the Respondent
A02

Age of the Respondent
A03

Gender of the Respondent
A04

Current designation at the facility
A05

Please indicate your highest qualification
A06

How long have you been working as a health provider after formal completion of your education?
A07

How long have you worked in the facility where you are currently posted?
A08

Do you provide family planning services at this facility?
A09

If no, can you tell us the reason for not providing family planning services?
A10

If yes, which type of family planning services do you provide?
A11

Do you provide FP counselling services to clients?
A12

Do you provide counselling for abortion at this facility?
A13

If no, can you tell us the reason for not providing abortion counselling services?
A14

Do you provide counselling for post abortion care at this facility?
A15

If no, can you tell us the reason for not providing counselling for post abortion care services?
A16

Do you provide sexual and reproductive health services/counselling to adolescents less than 10-1718 years of age?

A17

Which of the sexual and reproductive health services and counselling do you provide to adolescents from 10-17 years?
A18

If no, can you tell us the reason for not providing sexual and reproductive health services and counselling to adolescent from 10-17 yearsfriendly services?
Family Planning methods
B01

Can IUCD be given to a woman who had history of ectopic pregnancy?
B02

If the client develops reproductive tract infection any time after IUCD insertion, should IUCD be immediately removed by service provider?
B03

What are the specific advantages of an IUCD placed in the postpartum period (PPIUCD)?
B04

Would you insert IUCD within 10 minutes after placental delivery if woman has history of rupture of membranes (bag of water) 3 hours before the delivery?
B05

IUD can be placed after abortion – yes or no?
B06

Would you recommend an IUCD to a newly married couple with no children?
B07

What are the side effects of injectables/DMPA/Antara?
B08

When does fertility return after taking the last injection of DMPA
B09

If a lactating woman comes for her first MPA injection (Antara/ Depo-Provera/ DMPA) 4 months after giving birth, she is fully breastfeeding and her menses have not returned, can DMPA/Antara be given to her today?
B10

If a woman comes for DMPA/Antara injection on day 10 of her menstrual cycle, she can be given the injection, but she needs to be given a higher dose – True or False
B11

After woman gets 1st dose of Antara/DMPA injection, when should the 2nd dose be taken?
B12

If a woman needs to delay pregnancy by 3 years, how many minimum number of Antara/DMPA injections will she have to take?
B13

Would you recommend Antara to women 3 weeksjust after delivery who are breastfeeding?
B14

Do clients need to stop using DMPA/Antara and have a ‘rest’ after several injections?
B15

Who should not take Combined oral contraceptive pills/COCs?
B16

If a client forgets to take 1 pill of Combined Oral Contraceptives (COC), when she should she take the next dose
B17

If What to recommend if a person misses Combined OCP for 2 days what should be the course of action of taking doses on the next consecutive 3 days?
B18

What to recommend if a person misses Combined OCP for 3 days?
B19

Can ECs be used as a regular method of contraception?
B20

Within how many hours of intercourse can the EC pill be taken ?
B21

A woman who cannot use combined (estrogen-progestin) oral contraceptives or progestin-only pills as an ongoing method can still use emergency contraceptive pills (ECPs) safely - True or False
B22

The fetus will be harmed if a woman accidentally takes ECPs while she is pregnant – true or false.
B23

Which of the following is Chaya?
B24

If a woman misses a Chhaya/weekly pill, should she take the missed pill as soon as possible?
B25

Who should NOT take Chhaya/weekly pill? Women with:
Abortion and post abortion care
C01

In India, only doctors with post-graduate degree or diploma in gynaecology and obstetrics are legally allowed to carry out termination of pregnancy.
C02

Under what conditions/indications, can a pregnancy be terminated as per the MTP law?
C03

Consent of a guardian is required to terminate pregnancy in what case?
C04

As per MTP law, for pregnancy up to how many weeks opinion of one RMP is required for performing the MTP procedure?
C05

In India, with opinion of two doctors MTP can be legally performed up to 24 weeks of pregnancy– True or False
C06

No documentation is required in cases done with Medical Methods of Abortion since it does not involve a surgical procedure - True or False
C07

What documentation needs to be done/forms need to be filled in an abortion case?
C08

What are the possible complications that can develop after the abortion procedure?
C09

Which method of contraception should NOT be provided immediately following second trimester abortion ?
Adolescent health services
D01

Providing information on sexuality and safe sex to adolescents will do more harm than good -True or False
D02

If safe abortion services are made available and accessible to adolescents, it will encourage promiscuity.
D03

Nightfall in boys is
D04

Which temporary methods of contraception should be avoided in adolescent girls less than 17 years of age?
Counselling skills assessment
E01

Ruksana, 18 years old and Salim, 21 years old are a just married couple with no children. They do not want children for another 2 years as Salim has just started working and cannot support a child. They visit the nearby sub-centre for consultation on family planning. The busy ANM asks them to enter consultation room and quickly take their seat. She notes down their names in the register and asks them the purpose of their visit. Ruksana and Salim share their concern about not wanting a child so soon. But as their family was against contraception, they were not sure what to do. Interrupting Ruksana at this point, the ANM tells them she has seen many such cases from their community. Thinking that the couple would not adhere to any method regularly, the ANM told them they should use IUCD method for contraception. She told them that Ruksana should come on Tuesday to get the IUCD inserted at thePHC. The ANM handed them a pamphlet on IUCD and told them to read it before coming on Tuesday. The ANM called out for the next client.
E01A

The ANM was respectful in her behaviour towards Ruksana and Salim
E01B

The ANM was non-judgemental towards Ruksana and Salim and their situation.
E01C

The ANM suggested the right method for the couple as per their needs.
E01D

The ANM provided appropriate information to Ruksana and Salim.
E01E

The ANM provided appropriate referral for contraception to the young couple.
E02

During an OPD session, Kavita, a 16-year-old unmarried girl comes with her mother for a checkup at the hospital. She has been keeping unwell for a few weeks with occasional bouts of vomiting, especially in the morning. She seems to be the youngest among all the patients waiting there. The lady doctor calls Kavita and her mother into consultation room and greets them. After taking history form the Kavita, the doctor does an abdominal check-up in a private area while her mother waits outside. While doing the examination, Kavita tells her that she also has missed her periods. The doctor becomes suspicious that Kavita may be pregnant. The angry doctor asks Kavita to tell the truth as she thinks that she is 12 weeks pregnant. Scared Kavita reveals that she has a boyfriend and he had forced her to have sex a few times. The doctor scolds her that she should have concentrated on studying instead of having a relationship.
E02A

The doctor reacted appropriately to Kavita’s situation.
E02B

The doctor was non-judgemental towards Kavita and her situation.
E02C

The doctor gave Kavita the right legal information regarding abortion.
E02D

The doctor gave all the relevant information to Kavita regarding abortion.
E02E

The doctor provided appropriate referral advice to Kavita.
E03

Shardadevi, 21-years-old, is a mother of a 15 -month old boy. She recently found out that she was 12 weeks pregnant again. Already having a difficult previous pregnancy, she goes for an abortion to nearby CHC. For surgical abortion procedure, her husband takes a day off work to be present on the insistence of hospital staff to bring a guardian. After her surgical abortion procedure, the nurse comes at her bedside for post-abortion care counselling. The nurse who was going off-duty in half an hour, quickly told Shardadevi about self-care for following few days and danger signs for which she should immediately report to the health centre. While repeatedly glancing at watch and ignoring her husband, the nurse asked Shardadevi what method of contraceptive she wants to adopt. Shardadevi told her she was not sure as she had never used any method of contraception.

E03A

The nurse was respectful towards Shardadevi and her situation.
E03B

The nurse was non-judgemental towards Sharda’s situation while giving post-abortion care counselling.
E03C

The nurse suggested the right kind of family planning method considering Shardadevi’s needs.
E03D

The nurse gave all the relevant information regarding family planning methods to Shardadevi.
E03E

The nurse followed all the steps of appropriate counselling for Shardadevi’s counselling session.
E03F

Should Shardadevi’s husband be also included in family planning counselling?
E03G

Should the nurse suggest other methods of family planning to Shardadevi and her husband?
E03H

If yes, what methods of contraception should the nurse suggest to Shardadevi and her husband?
Service provision and referral mechanism
F01

How do you feel when discussing about family planning methods with your clients?

F02

Based on what criteria, do you suggest a particular method of family planning to a woman?
F03

Do you recommend Chaya to your clients anybody? (Yes / No)
F04

If no, then why do you not recommend Chhaya to your clientsanybody?
F05

What do you think are the biggest barriers to modern contraceptive uptake for households/community?
F06

Do you send clients to the counsellor for FP counselling?
F07

Do you send provide referral services for clients to the counsellorwho come for abortion counselling?
F08

Do Where do you send clients to refer the counsellor client for post abortion counselling care services?
F09

If Where do you refer the adolescents come approach you for services related to sexual and reproductive health issues, what do you do?
Information provision and information delivery mechanism
G01

When do you provide information related to family planning to women?
G02

Where do you provide information related to family planning to women?
G03

What are the methods you use for providing family planning related information to your clients?
G04

When do you provide information related to abortion to women?
G05

Where do you provide information related to abortion to women?
G06

When do you provide information related to post-abortion services to women?
G07

Where do you provide information related to post-abortion services to women?
G08

What are the methods/ job aid you use for providing abortion and post-abortion services related information to your clients?
G09

When do you provide information related to sexual and reproductive health related (SRH) issues to adolescents?
G10

Where do you provide information related to sexual and reproductive health related issues to adolescents?
G11

What are the methods/ job aids you use for providing information related to sexual and reproductive health related issues to adolescents?
Family Planning
H01

PPIUCD insertion training
H01A

Did you ever receive this training?
H01B

If not received, do you want this training?
H01C

Did you receive this training in last 12 months?
H01D

What were the topics covered in the training? (last 12 months)
H01E

Did you find this training useful? (last 12 months)
H02

IUCD insertion training
H02A

Did you ever receive this training?
H02B

If not received, do you want this training?
H02C

Did you receive this training in last 12 months?
H02D

What were the topics covered in the training? (last 12 months)
H02E

Did you find this training useful? (last 12 months)
H03

Injectable Contraceptive DMPA (Antara)
H03A

Did you ever receive this training?
H03B

If not received, do you want this training?
H03C

Did you receive this training in last 12 months?
H03D

What were the topics covered in the training? (last 12 months)
H03E

Did you find this training useful? (last 12 months)
H04

Centchromen (Chhaya)
H04A

Did you ever receive this training?
H04B

If not received, do you want this training?
H05

Oral Contraceptive Pills
H05A

Did you ever receive this training?
H05B

If not received, do you want this training?
H06

Emergency Contraceptive Pills
H06A

Did you ever receive this training?
H06B

If not received, do you want this training?
H07

Family planning counselling
H07A

Did you ever receive this training?
H07B

If not received, do you want this training?
H07C

Did you receive this training in last 12 months?
H07D

What were the topics covered in the training? (last 12 months)
H07E

Did you find this training useful? (last 12 months)
Adolescent Health
I01

Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic)
I01A

Did you ever receive this training?
I01B

If not received, do you want this training?
I01C

Did you receive this training in last 12 months?
I01D

What were the topics covered in the training? (last 12 months)
I01E

Did you find this training useful? (last 12 months)
I02

Swasthya Samwaad Kendra
I02A

Did you ever receive this training?
I02B

If not received, do you want this training?
I02C

Did you receive this training in last 12 months?
I02D

What were the topics covered in the training? (last 12 months)
I02E

Did you find this training useful? (last 12 months)
Male engagement for family planning
J01

According to you, who currently makes FP decisions in the household? (mark all that apply)
J02

In what percent of cases, do you recommend male condoms as a stand alone family planning method?
J03

Do you talk to men or women about using male condoms?
J04

Out of clients approaching you for FP services, inIn your experience, what percentage of males are willing / open to accept condoms?
J05

Out of clients approaching you for FP services, inIn your experience, what percentage of males are willing / open to accept NSVs?
J06

What are the challenges in talking to men?
J07

Do you need any extra training to be able to talk to men about family planning?
Workflow in abortion cases
K01

Have you ever seen a case of under 18 married teen pregnancy that may be unwanted
K02

If yes, what do you do in such cases?
K03

Have you ever seen a case of under 18 unmarried teen pregnancy that may be unwanted ?
K04

If yes, what do you do in such cases?
K05

Have you ever seen a case of unmarried pregnant woman above 18 years of age seeking abortion?
K06

If yes, what do you do in such cases?