Surveypoint

Q01

STATE NAME

Q02

STATE CODE

Q03

DISTRICT NAME

Q04

DISTRICT CODE

Q05

BLOCK NAME

Q06

BLOCK CODE

Q07

SUB-CENTER NAME

Q08

SUB-CENTER CODE

Q09

VILLAGE NAME

Q10

VILLAGE CODE

Q11

NAME OF ANM

Q12

ANM CODE

A01

INTERVIEWER NAME

A02

INTERVIEWER ID

A03

DATE OF VISIT

A04

RESULT CODE

INTERVIEW COMPLETED

visit rescheduled

INTERVIEW Incomplete

REFUSED

OTHER (SPECIFY)

A05

START TIME

B01

For how long have you been working as an ANM?

B02

For how long have you been working in this sub-center?

B03

Is there designated government building available for the Sub-Centre?

Yes

No

B04

In what year did the facility open?

B05

On average, how many days per week is the facility open?

B06

Are deliveries conducted at this SC?

Yes

No

C01

Is there additional ANM in the facility?

Yes

No

C02

Is there Male Health Worker at the facility?

Yes

No

C03

Is there Staff nurse available at the Sub Centre?

Yes

No

C04

Is there a Safai Karmachari at the facility?

Yes

No

C05

Does the role played by additional ANM helpful to you in providing better services?

Yes

No

C05A

What Role does she play?

Helps in providing clinical services at the SC

Stays at SC when I am in the field & vice-versa

Helps in maintaining records/ maintains records

Helps in conducting VHND/ Conducts VHND

Helps in Immunization/ Conducts Immunization

Helps in conducting/ Conducts Deliveries

Training of Sub ordinate staff

Other (Specify)

C06

Does the role played by Male health worker helpful to you in providing better services?

Yes

No

C06A

What Role does they play?

Performs role under different Vertical health programs

Health education/ IEC / BCC

Recording and reporting fever and other cases

Helps in organizing VHND

Helps in conducting Immunization

Other (Specify)

C07

Does the role played by Staff nurse helpful to you in providing better services?

Yes

No

C07A

What Role does they play?

Supervision and facilitation in running the SC

Supports and supervises the work done by Male/Female health Worker

Helps in maintaining records/ maintains records

Supervision and facilitation in conducting Immunization

Helps in conducting/ Conducts Deliveries

Training of Sub ordinate staff

Other (Specify)

C08

Does the role played by Safai Karmachari helpful to you in providing better services?

Yes

No

C08A

What Role does they play?

Maintaining cleanliness inside the facility

Maintaining cleanliness within premises of SC

Help in maintaining stocks and repository

Helps by assisting ANM/ Staff Nurse/ MPW

Other (Specify)

D01

Type of Sub Centre (SC) building?

Kacha

Semi-pucca

Pucca

D02

Number of rooms in the SC?

D03

Is there a designated waiting place for patients?

Yes

No

D04

Walk through the facility and compound area and based on observation rate the cleanliness

Clean

Somewhat clean

Dirty

D05

Is there siting arrangement for waiting patients?

Yes

No

D06

Is there arrangement for Drinking water within the premises?

Yes

No

D07

Is there 24 hour uninterrupted supply of Electricity

Yes

No

D08

Is there electricity backup at sub centre?

Yes

No

D09

Is there regular uninterrupted supply of water

Yes

No

D10

Is there proper toilet arrangement for male and female separately

Yes

No

D11

Is a working telephone (landline/mobile) facility available in the SC?

Landline in working condition

Mobile in working condition

Yes, both in working condition

Yes, but not in working condition

No connection

D12

How many beds are available in this SC (If no bed, record ‘0’)

D13

Number of beds in working condition with mattress and covered with clean bed sheets

D14

Has this SC been designated as Type A or Type B (MCH SC) by the state authority?

Yes

No

D15

Is there weighing machine in working condition in the Sub-Centre?

Yes

No

D16

Is there disposable delivery kits available in the Sub-Centre?

Yes

No

D17

Does the SC has a store room?

Yes

No

D18

Does your SC has a separate room for clinic/office?

Yes

No

D19

Does your SC has a refrigerator?

Yes

No

D20

Does your SC has a autoclave/boiler

Yes

No

D21

Does your SC has a cold box present for vaccine storage as per requirement?

Yes

No

D22

Does your SC has an ILR as per requirement?

Yes

No

D23

Does your SC has a deep freezer present for vaccine storage as per requirement?

Yes

No

E01

Name of the SC displayed clearly

Yes

No

E02

Displaying services available

Yes

No

E03

Display for Timings

Yes

No

E04

Display for Visit Schedule of "ANM"

Yes

No

E05

Availability of Suggestion/Complaint Box

Yes

No

F01

Examination Table

Yes

No

F02

Writing Table

Yes

No

F03

Chairs

Yes

No

F04

Stool

Yes

No

F05

Lamp

Yes

No

F06

Fans

Yes

No

F07

Tube lights

Yes

No

F08

RECORD BY OBSERVATION

F09

SC having packs of ORS on the day of interview

Yes

No

F10

SC having packs of zinc on the day of interview

Yes

No

F11

SC having packs of nebulizer on the day of interview

Yes

No

F12

SC having packs of nebulizing solution on the day of interview

Yes

No

F13

SC having IFA Tablets for pregnant women on the day of interview

Yes

No

F14

SC having IFA Tablets for adolescent girls (WIFS) on the day of interview

Yes

No

F15

SC having tablets or Injectable of Methergine on day of interview

Yes

No

F16

SC having Paracetamol 500 mg tablets on the day of interview

Yes

No

F17

SC having Albendazole 400 mg tablets on the day of interview

Yes

No

F18

Availability of Antibiotic: Amoxycillin

Yes

No

F19

Availability of Antibiotic: Ampicillin

Yes

No

F20

Availability of Antibiotic: Gentamycin

Yes

No

F21

Availability of Antibiotic: Metronidazole

Yes

No

F22

Availability of Antibiotic: Trimethoprim

Yes

No

F23

Availability of Antibiotic: Sulphamethoxazole

Yes

No

F24

Availability of Antibiotic: Ceftriaxone

Yes

No

F25

SC having tubes of Povidine Iodine ointment/ 100ml of Betadine 5 % w/w solution

Yes

No

F26

SC having Tetanus Toxoid injection on the day of Interview

Yes

No

F27

SC having drugs for MMA (Medical Method of Abortion), i.e., Misoprostal & Mifepristone on the day of interview

Yes

No

F28

SC having dicyclomine on the day of interview

Yes

No

F29

SC having IV fluid on the day of interview

Yes

No

F30

SC having vitamin K1 injection on the day of delivery

Yes

No

F31

Availability of Antihypertensive drugs such as Amlodipine, Losartan, Methldopa, Nifedipine etc.

Yes

No

F32

RTI/ STI Kit**

Yes

No

G01

SC having BCG vaccine on day of interview

Yes

No

G02

SC having OPV vaccine on day of interview

Yes

No

G03

SC having Hep B vaccine on day of interview

Yes

No

G04

SC having DPT vaccine on day of interview

Yes

No

G05

SC having measles vaccine on day of interview

Yes

No

G06

SC having Vitamin A syrup on day of interview

Yes

No

G07

SC having Pentavalent vaccine on day of interview

Yes

No

G08

SC having JE vaccine on day of interview

Yes

No

H01

Availability of Tab. and syrup Chloroquine for treatment of P. vivax

Yes

No

H02

Availability of DEC (Di Ethyle Carbamazine – only in Filaria endemic areas)

Yes

No

H03

Availability of Anti leprosy drugs (MDT Blister Packs)

Yes

No

H04

Availability of Rapid Diagnostic Kits for Malaria under National Vector Borne Disease Control Program.

Yes

No

H05

Availability of Anti-tuberculosis drugs as supplied under RNTCP

Yes

No

I01

Availability of Condoms (Nirodh)

Yes

No

I02

Availability of Oral pills

Yes

No

I03

Availability of Copper – T (380-A)

Yes

No

I04

Availability of Emergency contraceptive pills

Yes

No

I05

Ask only for Operational Labour Room at MCH Sub-centre

I06

SC with display of protocols for the Labour room

Yes

No

I07

SC with a labor table with Mattress, pillow and Kelly’s pad

Yes

No

I08

SC having McIntosh Sheet

Yes

No

I09

SC having Suction machine (Manual Vacuum Aspiration kit/ Electric Vacuum Aspiration Kit)

Yes

No

I10

SC having Facility for Oxygen administration

Yes

No

I11

SC having Sterilization equipment

Yes

No

I12

SC showing having Emergency drug tray: (Inj. Oxytocin, Inj Magnesium Sulphate, Inj. Methyl ergometrine maleate)

Yes

No

I13

SC having Clean linen/towel for receiving new born

Yes

No

I14

SC having inj. Dexamethasone

Yes

No

I15

Open care system: radiant warmer, fixed height, with trolley, drawers, O2-bottles

Yes

No

J01

Availability of Hub Cutter and Needle Destroyer

Yes

No

J02

Availability of Needle Destroyer

Yes

No

J03

Colour coded bins/ plastic bags for wastes of different kind

Yes

No

K01

SC having Mother and Child protection (MCP) Card

Yes

No

K02

Intra Venous Cannula

Yes

No

K03

SC having Rolls of cotton bandage

Yes

No

K04

SC having Rolls of Absorbent Cotton

Yes

No

K05

SC having Sterile Pads on the day of interview

Yes

No

K06

Extractor, mucus, ster, disp

Yes

No

K07

Tube, feeding, ster,disp

Yes

No

K08

Stock of Sterile Gloves

Yes

No

K09

Stock of Syringes

Yes

No

K10

Stock of AD Syringes for immunization

Yes

No

K11

Stock of Disposable Cord clamp

Yes

No

K12

Stock of sterile cord cutting equipment

Yes

No

K13

Stock of Disposable Sterile Urethral Catheter (rubber plain 12 fr)

Yes

No

K14

Stock of Dipsticks for urine test for protein and sugar

Yes

No

K15

Stock of Urine Pregnancy test Kits

Yes

No

K16

Stock of Disposable Sterile Swabs

Yes

No

K17

Stock of Glass Slide box

Yes

No

K18

Sub-centre/ANM having Routine Immunization Monitoring Chart

Yes

No

K19

Stock of Methylated spirit

Yes

No

K20

Availability of reagent for ABO Rh Blood Group Test

Yes

No

K21

Partograph charts

Yes

No

K22

Salt - Iodine test kit

Yes

No

K23

ANM reported having Home delivery Kit for SBA at the time of interview

Yes

No

K24

SC having soap on the day of interview

Yes

No

L01

Availability of Basin (Stainless Steel)

Yes

No

L02

Availability of Tray instrument/Dressing with

Yes

No

L03

Availability of Hemoglobin meter – set Sahli type complete

Yes

No

L04

Availability of Talquist Hb scale

Yes

No

L05

Availability of Surgical Scissors straight

Yes

No

L06

Availability of Sphygmomanometer Aneroid with cuff IS

Yes

No

L07

Availability of Vulsellum Uterine Curved Forcep

Yes

No

L08

Availability of Cusco’s/Graves Speculum

Yes

No

L09

Availability of Sims retractor/depressor/speculum

Yes

No

L10

Availability of Uterine Sound Graduated

Yes

No

L11

Availability of Plain Forceps

Yes

No

L12

Availability of Suture needle (straight or curved)

Yes

No

L13

Availability of BP apparatus with Stethoscope

Yes

No

L14

Availability of Foetoscope

Yes

No

L15

IV Stand

Yes

No

L16

HIV Screening**

Yes

No

L17

Hepatitis B Screening**

Yes

No

L18

Has the SC been supplied with any drug kit, at least once in the last 6 months

Yes

No

L19

Has the SC been supplied with at least one Drug Kit A in last 6 months?

Yes

No

L20

Has the SC been supplied with at least one Drug Kit B in last 6 months?

Yes

No

L21

How many deliveries on an average are done at the SC in a month?

L22

Does the facility for taking Peripheral blood smear in case of fever for detection available in the Sub-Centre?

Yes

No

L23

Does the SC provide contraceptive services like insertion of Copper – T, distributing Oral contraceptive pills or condoms provided by the Sub-Centre?

Yes

No

L24

Does the SC function as a Dot- Centre?

Yes

No

L25

Is there a new-born corner available in the facility?

Yes

No

M00

Beneficiary 1

M01

Age if the Beneficiary in completed years

M02

Sex of the Beneficiary

Male

Female

M03

Complaint

M04

Service Provided- Write detail for the treatment/ procedure done

M05

Was the Beneficiary satisfied as per your notice?

M06

Commentary on the service by ANM

M07

Beneficiary 2

M08

Age if the Beneficiary in completed years

M09

Sex of the Beneficiary

Male

Female

M10

Complaint

M11

Service Provided- Write detail for the treatment/ procedure done

M12

Was the Beneficiary satisfied as per your notice?

M13

Commentary on the service by ANM

N01

Number of beneficiaries that visited the sub-center

N02

Number of beneficiaries who availed counselling (including adolescent, pregnant mothers, post natal care of mother and early childhood care)

N03

Number of eligible women who received TT injection

N04

Number of eligible women who received IFA tablets

N05

No. of beneficiaries who availed Child Healthcare Services

N06

No. of beneficiaries who availed Family Planning Services

N07

No. of beneficiaries who availed treatment for RTI/STI

N08

No. of beneficiaries who availed treatment for Communicable diseases

N09

No of pregnant women who availed the service of delivery

N10

No of beneficiaries who availed the service of IUCD insertion

N11

No of beneficiaries who availed the service of DOTS

N12

SubCenter Observation Template -Form Fill

STATE NAME

STATE CODE

DISTRICT NAME

DISTRICT CODE

BLOCK NAME

BLOCK CODE

SUB-CENTER NAME

SUB-CENTER CODE

VILLAGE NAME

VILLAGE CODE

NAME OF ANM

ANM CODE

INTERVIEWER NAME

INTERVIEWER ID

DATE OF VISIT

RESULT CODE

START TIME

For how long have you been working as an ANM?

For how long have you been working in this sub-center?

Is there designated government building available for the Sub-Centre?

In what year did the facility open?

On average, how many days per week is the facility open?

Are deliveries conducted at this SC?

Is there additional ANM in the facility?

Is there Male Health Worker at the facility?

Is there Staff nurse available at the Sub Centre?

Is there a Safai Karmachari at the facility?

Does the role played by additional ANM helpful to you in providing better services?

What Role does she play?

Does the role played by Male health worker helpful to you in providing better services?

What Role does they play?

Does the role played by Staff nurse helpful to you in providing better services?

What Role does they play?

Does the role played by Safai Karmachari helpful to you in providing better services?

What Role does they play?

Type of Sub Centre (SC) building?

Number of rooms in the SC?

Is there a designated waiting place for patients?

Walk through the facility and compound area and based on observation rate the cleanliness

Is there siting arrangement for waiting patients?

Is there arrangement for Drinking water within the premises?

Is there 24 hour uninterrupted supply of Electricity

Is there electricity backup at sub centre?

Is there regular uninterrupted supply of water

Is there proper toilet arrangement for male and female separately

Is a working telephone (landline/mobile) facility available in the SC?

How many beds are available in this SC (If no bed, record ‘0’)

Number of beds in working condition with mattress and covered with clean bed sheets

Has this SC been designated as Type A or Type B (MCH SC) by the state authority?

Is there weighing machine in working condition in the Sub-Centre?

Is there disposable delivery kits available in the Sub-Centre?

Does the SC has a store room?

Does your SC has a separate room for clinic/office?

Does your SC has a refrigerator?

Does your SC has a autoclave/boiler

Does your SC has a cold box present for vaccine storage as per requirement?

Does your SC has an ILR as per requirement?

Does your SC has a deep freezer present for vaccine storage as per requirement?

Name of the SC displayed clearly

Displaying services available

Display for Timings

Display for Visit Schedule of "ANM"

Availability of Suggestion/Complaint Box

Examination Table

Writing Table

Chairs

Stool

Lamp

Fans

Tube lights

RECORD BY OBSERVATION var statement=document.write(localStorage.getItem('total'));

SC having packs of ORS on the day of interview

SC having packs of zinc on the day of interview

SC having packs of nebulizer on the day of interview

SC having packs of nebulizing solution on the day of interview

SC having IFA Tablets for pregnant women on the day of interview

SC having IFA Tablets for adolescent girls (WIFS) on the day of interview

SC having tablets or Injectable of Methergine on day of interview

SC having Paracetamol 500 mg tablets on the day of interview

RECORD BY OBSERVATION

Ask only for Operational Labour Room at MCH Sub-centre