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Public Health Assessment -Form Fill
FACILITY IDENTIFICATION
Q01
Name of facility
Q02
Facility code
Q03
State
Q04
District Code
Q05
District Name
Q06
Block code
Q07
Block name
Q08
Level of facility
L1
L2
L3
Q09
Type of facility
District hospital
Sub-district hospital
First referral unit (FRU) Community Health Center
Non FRU- Community Health Center
Primary Health Center
GENERAL INFORMATION
A01
Name of the respondent
A02
Designation of the respondent
Medical Superintendent
Superintendent
Hospital Manager
Medical Officer in Charge of the Hospital
Other best - informed person (specify)
A03
Telephone number of the respondents
A04
INTERVIEW START TIME
A05
INTERVIEW END TIME
INFRASTRUCTURE
B01
Does this facility have a functioning land line telephone that is available to call at all times client services are offered?
Yes
No
B02
Does this facility have a functioning cellular telephone or a private cellular phone that is supported by the facility?
Yes
No
B03
Does this facility have a functioning computer?
Yes
No
B04
Is there access to email or internet within the facility today?
Yes
No
B05
Does this facility have its OWN affiliated ambulance/vehicle which is used for transportation of patients/clients?
Yes
No
B06
Does this facility have 102/108 SPECIAL emergency ambulance services facility?
Yes, 102 only
Yes, 108 only
Yes, 102 and 108 both
No
B07
Is fuel for the ambulance or other emergency vehicle available today?
Yes
No
B08
Does your facility have electricity from any source (e.g. electricity grid, generator, solar, or other) including for stand-alone devices (EPI cold chain)?
Yes
No
B09
What is the regularity of power supply in a normal day?
More than 20 hours
13-20 hours
6-12 hours
Less than 6 hours
B10
What is the electricity used for in the facility?
Only stand-alone electric medical Devices/appliances (e.g. epi cold room, refrigerator, suction apparatus, etc.)
Electric lighting (excluding flashlights) and communications
Electric lighting, communications, and 1 to 2 electric medical devices/ appliances
All electrical needs of facility
B11
Other than the main or primary source, does the facility have a secondary or backup source of electricity?
No secondary source
Generator/ invertor
Solar system
Other
B12
Is the generator/ invertor functional?
Yes
No
B13
Is the solar system functional?
Yes, functioning
Partially, battery needs servicing/replacement
No, not functional
Don’t know
B14
How many days of the week is this facility open ?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
B15
On average, how many hours per day is this facility open?
4 hours or less
5 to 8 hours
9 to 16 hours
17 to 23 hours
24 hours
B16
What is the most commonly used source of water for the facility at this time?
Piped
Water from protected well/borehole
Water from unprotected well/borehole
Surface water
Other
B17
Is water available from this source on facility premises?
Yes
No
B18
Is there a toilet (latrine) on premises in functioning condition that is accessible for general outpatient client use?
Yes
No
B19
Does this facility have any guidelines on standard precautions for infection prevention?
Yes, observed
Yes, reported not seen
No
B20
When was the last time this facility received a supervision visit from the higher level?
This month
In the last 3 months
More than 3 months ago
Don’t know
B21
Who came for the last supervision visit?
Officials from state
CMHO
Civil surgeon of the DH
MoIC of the CHC
MO of PHC
Any other (please specify)
Don’t know
B22
During the last supervision visit, did the supervisor assess the following?
B22_1
Pharmacy (e.g. drug stock out, expiry, records, etc.)
Yes
No
B22_2
Staffing (e.g. staff available and training)
Yes
No
B22_3
Data (e.g. completeness, quality, and timely reporting)
Yes
No
B23
Does this facility have counselors?
Yes
No
B24
If yes, which all counsellors are present?
B24_1
FP counsellor
Yes
No
B24_2
Adolescent health counsellor
Yes
No
B24_3
Women health counsellor
Yes
No
B24_4
ICTC/ STI counsellor
Yes
No
B24_5
Swasthya Samwaad kendra counsellor
Yes
No
AVAILABILITY OF ABORTION SERVICES.
C01
Name of the respondent
C02
Designation of the respondent
Medical Superintendent
Superintendent
Hospital Manager
Medical Officer in Charge of the Hospital
Other best - informed person (specify)
C03
Phone number of the respondent
C04
Does this facility offer abortion ?
Yes
No
C05
If no, then what are the reasons for not offering abortion services?
Supplies not available
Equipment not available
Trained staff not available
Abortions are illegal in India
Other
C06
If yes, which type of abortion (medical, surgical, both) services are offered?
Medical abortion services
Surgical abortion services
Both Medical and surgical abortion services
C07
Does this facility offer post abortion family planning services?
Yes
No
C08
Does this facility offer post abortion counselling services?
Yes
No
C09
Ask the respondent to tell about the providers in the health facility who are involved in providing abortion and post abortion services
C09A
total comprehensive abortion care (CAC) trained persons
C09A_1
Obstetrician & Gynaecologist (6 days CAC training)
C09A_2
Other specialist (MD/MS in filed other than obstetrics and gynaecologist) (12 days CAC training)
C09A_3
Medical Officers/ lady medical officer i.e. LMO (non-specialist, MBBS)/ ( 12 days CAC training)
C09A_4
AYUSH
C09A_5
Staff nurses (4 days CAC training)
C09A_6
ANMs/LHVs
C09A_7
Pharmacist
C09A_8
Laboratory technician
C09B
how many have been assigned a mentore
C09B_1
Obstetrician & Gynaecologist (6 days CAC training)
C09B_2
Other specialist (MD/MS in filed other than obstetrics and gynaecologist) (12 days CAC training)
C09B_3
Medical Officers/ lady medical officer i.e. LMO (non-specialist, MBBS)/ ( 12 days CAC training)
C09B_4
AYUSH
C09B_5
Staff nurses (4 days CAC training)
C09B_6
ANMs/LHVs
C09B_7
Pharmacist
C09B_8
Laboratory technician
C10
Verify if there is a client waiting area with seating that is sheltered from sun and rain at the clinic.
Yes
No
C11
Observe following in OPD
C11_1
Is there Seating arrangement in the OPD for client/woman, accompanying person?
Yes
No
C11_2
Is IEC material related to abortion (posters, calendar, flip charts, pamphlets etc) displayed?
Yes
No
C11_3
If yes, does they have following?
Legality
Rights
Method options
Symptoms of pregnancy
Complications of abortions
C11_4
Is there a sign on the street or on the exterior of the building announcing that safe abortion services are available here?
Yes
No
C12
OBSERVE if the following resources/supplies used for infection control are available in the general OPD today.
C12_1
Clean running water (piped, bucket with tap, or pour pitcher)
Yes
No
C12_2
Hand-washing soap/liquid soap
Yes
No
C12_3
Alcohol based hand rub
Yes
No
C12_4
Disposable latex gloves
Yes
No
C12_5
Waste receptacle (pedal bin) with lid and plastic bin liner
Yes
No
C12_6
Sharps container ("safety box")
Yes
No
C12_7
Environmental disinfectant (e.g., chlorine, alcohol)
Yes
No
C12_8
Disposable syringes with disposable needles
Yes
No
C12_9
Auto-disable syringes
Yes
No
C12_10
Colour coded bins
Yes
No
C13
May I see where clients for abortion are examined?
Separate room, no ability to see into the room from outside
Behind a curtain
No privacy
C14
Does examination room have following items
C14A
Gynac Examination table
Yes
No
C14B
Hand washing facility
Yes
No
C14C
Display of technical protocols of abortion
Yes
No
C14D
Cusco’s speculum medium
C14D_1
PHC/ Non FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C14D_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C14D_3
District hospital
Yes, atleast 5 present
yes, less than 5 present
no
C14E
Cusco’s speculum – Large
C14E_1
PHC/ Non FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C14E_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C14E_3
District hospital
Yes, atleast 5 present
yes, less than 5 present
no
C14F
SIM’s speculum- medium
C14F_1
PHC/ Non FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C14F_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C14F_3
District hospital
Yes, atleast 5 present
yes, less than 5 present
no
C14G
SIM’s speculum – Large
C14G_1
PHC/ Non FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C14G_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C14G_3
District hospital
Yes, atleast 5 present
yes, less than 5 present
no
C14H
Light Source
Yes
No
C14I
Foot step
Yes
No
C15
OT or procedure room where abortion services are provided?
C15A
Labor table/ Gynac Examination Table
Yes
No
C15B
Foot step
Yes
No
C15C
Light source (lamp)
Yes
No
C15D
Suction machine
Yes
No
C15E
MVA/EVA Aspirator
C15E_1
PHC/ Non FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C15E_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C15E_3
District hospital
Yes, atleast 5 present
yes, less than 5 present
no
C15F
Tenaculum
Yes
No
C15G
Product of conception (POC) check
Yes
No
C15H
Sterilized consumables like cotton and gauze
Yes
No
C15I
Plastic bucket/tub for decontamination
Yes
No
C15J
Bleaching powder
Yes
No
C15K
Utility gloves
Yes
No
C15L
Soap
Yes
No
C15M
Leak proof color coded covered container for disposables
Yes
No
C15N
Water for washing
Yes
No
C16
Check if the following instrument are present in the facility.
C16A
Cheatle's forceps
C16A_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16A_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16A_3
DH
Yes, atleast 3 present
yes, less than 3 present
no
C16B
Anterior vaginal wall retractor
C16B_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16B_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16B_3
DH
Yes, atleast 3 present
yes, less than 3 present
no
C16C
Valsellum/ Allis Foreceps
C16C_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16C_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16C_3
DH
Yes, atleast 3 present
yes, less than 3 present
no
C16D
Dilator set
C16D_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16D_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16D_3
DH
Yes, atleast 3 present
yes, less than 3 present
no
C16E
Sim's speculum (medium and large)
C16E_1
PHC/ NON-FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C16E_2
FRU CHC/ SDH
Yes, atleast 4 present
yes, less than 4 present
no
C16E_3
DH
Yes, atleast 5 present
yes, less than 5 present
no
C16F
Sponge holding forceps
C16F_1
PHC/ NON-FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C16F_2
FRU CHC/ SDH
Yes, atleast 3 present
yes, less than 3 present
no
C16F_3
DH
Yes, atleast 5 present
yes, less than 5 present
no
C16G
Sharp and blunt curette (for checking quantity count both)
C16G_1
PHC/ NON-FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C16G_2
FRU CHC/ SDH
Yes, atleast 3 present
yes, less than 3 present
no
C16G_3
DH
Yes, atleast 5 present
yes, less than 5 present
no
C16H
Ovum forceps
C16H_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16H_2
DH
Yes, atleast 2 present
yes, less than 2 present
no
C16I
Cannulae of different sizes
C16I_1
PHC/ NON-FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C16I_2
FRU CHC/ SDH
Yes, atleast 3 present
yes, less than 3 present
no
C16I_3
DH
Yes, atleast 5 present
yes, less than 5 present
no
C16J
Bowl/kidney tray (antiseptic)
C16J_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16J_2
FRU CHC/ SDH
Yes, atleast 3 present
yes, less than 3 present
no
C16J_3
DH
Yes, atleast 5 present
yes, less than 5 present
no
C16K
Instrument tray
C16K_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16K_2
FRU CHC/ SDH
Yes, atleast 3 present
yes, less than 3 present
no
C16K_3
DH
Yes, atleast 5 present
yes, less than 5 present
no
C16L
Knife holder No.4
C16L_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16L_2
DH
Yes, atleast 1 present
no
C16M
Knife blade no.23
C16M_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16M_2
DH
Yes, atleast 1 present
no
C16N
Tooth forcep SS
C16N_1
FRU CHC/ SDH
Yes, atleast 4 present
yes, less than 4 present
no
C16N_2
DH
Yes, atleast 4 present
yes, less than 4 present
no
C16O
Halstead mosquito forcep 12.5c- curved SS
C16O_1
FRU CHC/ SDH
Yes, atleast 4 present
yes, less than 4 present
no
C16O_2
DH
Yes, atleast 4 present
yes, less than 4 present
no
C16P
Halstead mosquito forcep 12.5c- straight SS
C16P_1
FRU CHC/ SDH
Yes, atleast 6 present
yes, less than 6 present
no
C16P_2
DH
Yes, atleast 6 present
yes, less than 6 present
no
C16Q
Allis forcep 20cm SS
C16Q_1
FRU CHC/ SDH
Yes, atleast 4 present
yes, less than 4 present
no
C16Q_2
DH
Yes, atleast 4 present
yes, less than 4 present
no
C16R
Babcock forcep straight 20cm SS
C16R_1
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16R_2
DH
Yes, atleast 2 present
yes, less than 2 present
no
C16S
Needle holder 8 inch – straight SS
C16S_1
FRU CHC/ SDH
Yes, atleast 6 present
yes, less than 6 present
no
C16S_2
DH
Yes, atleast 6 present
yes, less than 6 present
no
C16T
Towel clips (backhous) 13 cm SS
C16T_1
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16T_2
DH
Yes, atleast 2 present
yes, less than 2 present
no
C16U
Sponge holding forceps (forester/ straight/ serrated) 25cm SS
C16U_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16U_2
DH
Yes, atleast 1 present
no
C16V
Mayo operating scissors: curved, blunt-pointed, 17cm SS
C16V_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16V_2
DH
Yes, atleast 1 present
no
C16W
Mayo operating scissors, straight, blunt-pointed, 17cm SS
C16W_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16W_2
DH
Yes, atleast 1 present
no
C16X
Devers retractor
C16X_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16X_2
DH
Yes, atleast 1 present
no
C16Y
Retractor – Doyens big SS
C16Y_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16Y_2
DH
Yes, atleast 1 present
no
C16Z
Retractor – Doyens small SS
C16Z_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16Z_2
DH
Yes, atleast 1 present
no
C16AA
Suture cutting scissors SS
C16AA_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16AA_2
DH
Yes, atleast 1 present
no
C16BB
Plain forcep
C16BB_1
FRU CHC/ SDH
Yes, atleast 1 present
no
C16BB_2
DH
Yes, atleast 1 present
no
C16CC
Uterine haemostatic forceps (green armtage clamps) 21cm SS
C16CC_1
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16CC_2
DH
Yes, atleast 2 present
yes, less than 2 present
no
C16DD
Kochers forcep – small
C16DD_1
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16DD_2
DH
Yes, atleast 2 present
yes, less than 2 present
no
C16EE
Kochers forcep – big
C16EE_1
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C16EE_2
DH
Yes, atleast 2 present
yes, less than 2 present
no
C16FF
Instrument trolley
C16FF_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C16FF_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C16FF_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C17
Ask the respondent if the following resuscitation equipment are present in the facility
C17A
Oral airway – adult
C17A_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C17A_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C17A_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C17B
Face mask– adult
C17B_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C17B_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C17B_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C17C
Ambu bag– adult
C17C_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C17C_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C17C_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C17D
Oxygen cylinder with reducing valve flow meter
C17D_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C17D_2
FRU CHC/ SDH
Yes, atleast 2 present
yes, less than 2 present
no
C17D_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C17E
Endotracheal tubes – adult
C17E_1
PHC/ NON-FRU CHC
Yes
No
C17E_2
FRU CHC/ SDH
Yes
No
C17E_3
DH
Yes
No
C17F
Boyle’s apparatus
C17F_1
DH
Yes, atleast 1 present
no
C18
Ask the respondent if the following resuscitation equipment are present in the facility
C18A
Autoclave
C18A_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C18A_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C18A_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C18B
Boiler
C18B_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C18B_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C18B_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C18C
Cider Tray / cidex tray
C18C_1
PHC/ NON-FRU CHC
Yes, atleast 1 present
no
C18C_2
FRU CHC/ SDH
Yes, atleast 1 present
no
C18C_3
DH
Yes, atleast 2 present
yes, less than 2 present
no
C19
Ask the respondent if the following drugs are present in the facility.
C19A
Tab Misoprostol (200 microgm)
C19A_1
PHC/ NON-FRU CHC
Yes, atleast 16 present
yes, less than 16 present
no
C19A_2
FRU CHC/ SDH
Yes, atleast 26 present
yes, less than 26 present
no
C19A_3
DH
Yes, atleast 80 present
yes, less than 80 present
no
C19A1
Count number of unexpired Tab Misoprostol in ward (200 microgm)
C19A2
Count number of unexpired Tab Misoprostol in store (200 microgm)
C19B
Tab Misoprostol (100 microgm)
C19B_1
PHC/ NON-FRU CHC
Yes, atleast 32 present
yes, less than 32 present
no
C19B_2
FRU CHC/ SDH
Yes, atleast 52 present
yes, less than 52 present
no
C19B_3
DH
Yes, atleast 160 present
yes, less than 160 present
no
C19B1
Count number of unexpired Tab Misoprostol in ward(100 microgm)
C19B2
Count number of unexpired Tab Misoprostol in store (100 microgm)
C19C
Tab Mifepristone
C19C_1
PHC/ NON-FRU CHC
Yes, atleast 2 present
yes, less than 2 present
no
C19C_2
FRU CHC/ SDH
Yes, atleast 3 present
yes, less than 3 present
no
C19C_3
DH
Yes, atleast 10 present
yes, less than 10 present
no
C19C1
Count number of unexpired Tab Mifepristone in ward
C19C2
Count number of unexpired Tab Mifepristone in store
C19D
Combi pack of miso and mife
Yes
No
C19D1
Count number of unexpired compi pack in ward
C19D2
Count number of unexpired compi pack in store
C19E
Antibiotics-Tab Doxycycline
Yes
No
C19F
Cap Ampicillin
Yes
No
C19G
Analgesics-Tab Ibuprofen
Yes
No
C19H
Tab Emeset (Ondensetron)
Yes
No
C19I
Tab Lomotil
Yes
No
C19J
Inj. Ethacridine Lactate(set of vials)
Yes
No
C19K
Inj. Methylergometrine – Mandatory
Yes
No
C19L
In j. Oxytocin (refregirated or heat stable)
Yes
No
C19M
In j. Xylocaine/Lignocaine (vials)
Yes
No
C19N
5% Dextrose
Yes
No
C19O
Ringer lactate
Yes
No
C19P
Normal saline
Yes
No
C19Q
In j. Diazepam
Yes
No
C19R
In j. Atropine
Yes
No
C19S
In j. Adrenaline
Yes
No
C19T
Inj. Aminophylline
Yes
No
C19U
Inj. Sodium bi-carbonate 7.5%
Yes
No
C19V
Inj. Calcium gluconate- 10%
Yes
No
C19W
Inj. Perinorm/ injection Ondesterone
Yes
No
C19X
Inj. Avil/Phenergan
Yes
No
C19Y
Inj. Hyclrocortisone
Yes
No
C19Z
Inj. Frusemide
Yes
No
C19AA
Inj. Dopamine
Yes
No
C20
Ask the respondent if the following consumable are present in the facility.
C20_1
Povidone iodine solution bottles
Yes
No
C20_2
Bleaching powder/Hypochlorite solution
Yes
No
C20_3
Disposable syringes (2 / 5 ml)
Yes
No
C20_4
Disposable syringes (10 / 20 ml/)
Yes
No
C20_5
IV sets
Yes
No
C20_6
IV cannula/scalp vein sets
Yes
No
C20_7
Surgical gloves (pairs)
Yes
No
C20_8
Utility gloves
Yes
No
C20_9
Cotton /gauze
Yes
No
C20_10
Foley 's catheter of different sizes (14 size)
Yes
No
C20_11
Plastic gowns
Yes
No
C20_12
Perineal Sheet
Yes
No
C20_13
Trolley sheet
Yes
No
C20_14
Surgical masks (disposable)
Yes
No
C20_15
Head caps (disposable)
Yes
No
C20_16
OT slippers
Yes
No
C21
Does this facility provide IUCD services?
Yes
No
C22
Ask the respondent: “May I see the OT where IUCD services are provided?”
C22_1
Linen/cloth to cover the woman’s pelvic area
Yes
No
C22_2
Stainless steel tray with cover
Yes
No
C22_3
Small bowl for antiseptic solution
Yes
No
C22_4
Uterine sound
Yes
No
C22_5
Mayo scissors
Yes
No
C22_6
Long artery straight forceps (for IUCD removal)
Yes
No
C22_7
Gloves (high-level disinfected/sterile surgical gloves or examination gloves)
Yes
No
C22_8
Dry cotton swabs
Yes
No
C22_9
Torch
Yes
No
C22_10
IUCD (in an unopened, undamaged, sterile package and the date of expiry is not over)
Yes
No
C22_11
Kelly placental forceps or long placental forceps or ringed placental forceps
Yes
No
C23
Ask the respondent to show you various forms/ documents/ registers related to abortion and post abortion services maintained in the facility.
C23_1
Form C-Consent Form
Yes
No
C23_2
Form I-RMP Opinion Form
Yes
No
C23_3
Form III-Admission Register
Yes
No
C23_4
Form II/Monthly reporting to the district health authority (CMHO)
Yes
No
C23_5
Quarterly reporting format given by Maternal Health Division, MoHFW
Yes
No
C23_6
Are abortion registers maintained in the health facility?
Yes, separate register for Medical and surgical abortion
Yes, combined register for Medical and surgical abortion
No register maintained
C23_7
Are registers being used?- ask
Always used
Sometimes used
Never used
C23_8
Are MMA follow up cards available in the health facility?
Yes
No
C24
Please check the stock register of misoprostol for the past 3 months and note down the lowest value of ‘current stock’
C25
Please check the stock register of mifepristone for the past 3 months and note down the lowest value of ‘current stock’
C26
Please check the stock register of combi pack for the past 3 months and note down the lowest value of ‘current stock’
C27
Has this facility provided medical abortion in the last 90 days?
Yes, registered
Yes, but register not available
No case in last 90 days
C28
Has this facility provided surgical abortion (using MVA) in the last 90 days?
Yes, registered
Yes, but register not available
No case in last 90 days
C29
Does this facility maintain any register on post abortion care?
Yes
No
C30
Among the surgical and medical abortions done in last 90 days, how many cases were provided with post-abortion family planning method?
C31
Among the post abortion family planning methods provided in last 90 days, how many cases were provided with IUCD method?
C32
Out of the following list, what all complications can be managed at this facility? (Please do not mark those complications for which you stabilize patient and refer to a higher facility)
Sepsis
Fever
Haemorrhage and excessive vaginal bleedind because of abortion
Uterus perforation
Shock
Incomplete abortion – need for uterine evacuation
Continuation of pregnancy
Asherman’s syndrome
Pelvic inflammatory disease(PID)
None
C33
At this facility, after abortion is follow up done through doctors, nurses, ASHAs?
Yes
No
AVAILABLE FAMILY PLANNING SERVICES IN THE FACILITY
D01
Name of the respondent
D02
Designation of the respondent
Medical Superintendent, Hospital
Superintendent
Hospital Manager
Medical Officer in Charge of the Hospital
Other best - informed person (specify)
D03
Phone number of the respondent
D04
Does this facility offer family planning services?
Yes
No
D05
Ask the respondent to tell about the providers in the health facility who are involved in providing Family planning services.
D05A
Total number
D05A_1
Obstetrician & Gynaecologist
D05A_2
Other specialist (MD/MS in field other than obstetrics and gynaecology)
D05A_3
Medical Officers/ lady medical officer (non-specialist, MBBS)
D05A_4
AYUSH (non RBSK)
D05A_5
Staff nurses
D05A_6
ANMs/LHVs
D05A_7
Pharmacist
D05A_8
Laboratory technician
D05B
Trained in providing IUCD (5 days)
D05B_1
Obstetrician & Gynaecologist
Yes
No
D05B_2
Other specialist (MD/MS in field other than obstetrics and gynaecology)
Yes
No
D05B_3
Medical Officers/ lady medical officer (non-specialist, MBBS)
Yes
No
D05B_4
AYUSH (non RBSK)
Yes
No
D05B_5
Staff nurses
Yes
No
D05B_6
ANMs/LHVs
Yes
No
D05C
Trained and mentored in providing PPIUCD (5 days)
D05C_1
Obstetrician & Gynaecologist
Yes
No
D05C_2
Other specialist (MD/MS in field other than obstetrics and gynaecology)
Yes
No
D05C_3
Medical Officers/ lady medical officer (non-specialist, MBBS)
Yes
No
D05C_4
AYUSH (non RBSK)
Yes
No
D05C_5
Staff nurses
Yes
No
D05C_6
ANMs/LHVs
Yes
No
D05D
Trained in providing sterilization
D05D_1
Obstetrician & Gynaecologist
Yes
No
D05D_2
Other specialist (MD/MS in field other than obstetrics and gynaecology)
Yes
No
D05D_3
Medical Officers/ lady medical officer (non-specialist, MBBS)
Yes
No
D05E
Trained in providing injectable
D05E_1
Obstetrician & Gynaecologist
Yes
No
D05E_2
Other specialist (MD/MS in field other than obstetrics and gynaecology)
Yes
No
D05E_3
Medical Officers/ lady medical officer (non-specialist, MBBS)
Yes
No
D05E_4
Staff nurses
Yes
No
D05E_5
ANMs/LHVs
Yes
No
D06
Verify if there is a client waiting area with seating that is sheltered from sun and rain at the clinic.
Yes
No
D07
Ask the respondent: “May I see where family planning clients are examined?”
Separate room, no ability to see into the room from outside
Behind a curtain
Other area that ensures privacy
No privacy
D08
Does this facility have following IEC material?
Yes
No
D08_1
Is there a sign on the street or on the exterior of the building announcing that family planning services are available?
Yes
No
D08_2
Clients' rights displayed at a prominent place at the facility
Yes
No
D08_3
Board displaying service timings
Yes
No
D08_4
Availability of free and paid services displayed on wall painting
Yes
No
D08_5
Signboard indicating the direction for service point displayed
Yes
No
D08_6
Flip charts, models, specimens and samples of contraceptives available in the counselling room
Yes
No
D08_7
IEC materials such as poster, banner and handbills available at the site and displayed
Yes
No
D08_8
Suggestion and complaint system for clients (Complaint box or book)
Yes
No
D09
Does this facility provide or prescribe any of the following modern methods of family planning?
D09_1
Male condoms
Yes
No
D09_2
Combined (estrogen progesterone oral) contraceptive pills (COC)
Yes
No
D09_3
Weekly pills (non-steroidal, non- hormonal contraceptive pills)/ Chhaya pills
Yes
No
D09_4
Emergency contraceptive
Yes
No
D09_5
Injectable contraceptive (Antara/ DMPA)
Yes
No
D09_6
IUCD 380A
Yes
No
D09_7
IUCD 375A
Yes
No
D09_8
Pregnancy testing kits (PTKs)
Yes
No
D09_9
Male sterilization
Yes
No
D09_10
Female sterilization
Yes
No
D09A
If no, then why?
D09A_1
Male condoms
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_2
Combined (estrogen progesterone oral) contraceptive pills (COC)
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_3
Weekly pills (non-steroidal, non- hormonal contraceptive pills)/ Chhaya pills
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_4
Emergency contraceptive
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_5
Injectable contraceptive (Antara/ DMPA)
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_6
IUCD 380A
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_7
IUCD 375A
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_8
Pregnancy testing kits (PTKs)
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_9
Male sterilization
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D09A_10
Female sterilization
Supplies not Available
Equipment not available
Inhouse trained staff not available
Lack of demand from patients
Other
D10
Are any of the following Family planning commodities available in this service site today?
D10_1
Male condoms
Yes, observed
Yes, reported
No
D10_2
Female condoms
Yes, observed
Yes, reported
No
D10_3
Combined (estrogen progesterone oral) contraceptive pills (COC)
Yes, observed
Yes, reported
No
D10_4
Weekly pills (non-steroidal, non- hormonal contraceptive pills)/ Chhaya pills
Yes, observed
Yes, reported
No
D10_5
Progesterone only pills
Yes, observed
Yes, reported
No
D10_6
Emergency contraceptive
Yes, observed
Yes, reported
No
D10_7
Injectable contraceptive (Antara/ DMPA)
Yes, observed
Yes, reported
No
D10_8
IUCD 380A
Yes, observed
Yes, reported
No
D10_9
IUCD 375A
Yes, observed
Yes, reported
No
D10_10
Pregnancy testing kits (PTKs)
Yes, observed
Yes, reported
No
D10_11
Tubal rings
Yes, observed
Yes, reported
No
D11
Please check the stock register of condom for the past 3 months and note down the lowest value of ‘current stock’
D12
Please check the stock register of combined oral contraceptive for the past 3 months and note down the lowest value of ‘current stock’
D13
Please check the stock register of weekly pills/ chhaya for the past 3 months and note down the lowest value of ‘current stock’
D14
Please check the stock register of emergency contraceptive for the past 3 months and note down the lowest value of ‘current stock’
D15
Please check the stock register of injectable/ DMPA for the past 3 months and note down the lowest value of ‘current stock’
D16
Please check the stock register of IUCD380A for the past 3 months and note down the lowest value of ‘current stock’
D17
Please check the stock register of IUCD375A for the past 3 months and note down the lowest value of ‘current stock’
D18
Please check the stock register of pregnancy testing kit for the past 3 months and note down the lowest value of ‘current stock’
D19
Ask the respondent to show various register related FP services which are maintained at the facility.
D19_1
PPIUCD register
Yes, observed
Yes, reported not seen
No
D19_2
IUCD register
Yes, observed
Yes, reported not seen
No
D19_3
Chhaya register
Yes, observed
Yes, reported not seen
No
D19_4
Antara register
Yes, observed
Yes, reported not seen
No
D20
Number of IUCD provided in last 90 days (3 months)
D21
Number of PPIUCD provided in last 90 days (3 months)
D22
Number of Injectable (DMPA/Antara) provided in last 90 days (3 months)
Adolescent health friendly services availability in the health facility
E01
Name of the respondent
E02
Designation of the respondent
Medical Superintendent, Hospital
Superintendent
Hospital Manager
Medical Officer in Charge of the Hospital
Other best - informed person (specify)
E03
Phone number of the respondent
E04
Is this facility in mandate of government to have RKSK AFHC?
Yes
No
E05
Do you wish to have RKSK AFHC in this facility?
Yes
No
E06
Does this facility provide Adolescent health services/ youth friendly services?
Yes
No
E07
Is there a separate cell/ place/infrastructure for RKSK Adolescent Friendly Health Centre and Swasthya Samwaad kendra?
Yes, separate cell/ place for both
No (there is a combined place/cell)
E08
Does this facility offer family planning services for adolescents during weekend hours at least once per month?
Yes
No
E09
Does this facility offer family planning services for adolescents during any hours during the evening (after 5pm)?
Yes
No
E10
Are referral mechanisms in place to serve adolescent needs? (for medical emergencies, for mental health and psychosocial support, etc)
Yes
No
E11
Are contraceptives available to young adolescents over 15 years?
Yes
No
E12
Is a wide range of SRH services available? (FP, STI treatment and prevention, HIV counselling and testing, antenatal and postnatal care, delivery care)
Yes
No
E13
Does this health facility have an RKSK Adolescent Friendly Health service trained Medical officer (MO)?
Yes
No
E14
If yes, how many
E15
Does this health facility have dedicated Adolescent health counsellor?
Yes
No
E16
Does this clinic have an affiliated LHV/ANM?
Yes
No
E17
Is there a separate room for providing RKSK Adolescent health services/ youth friendly services?
Yes, separate room
Yes, available room is sub-divided to create space/room for the Adolescent Friendly Health Clinics.
No separate room
E18
Does RKSK AFHC room have privacy?
Yes, visual privacy (A room where others are not likely to see interactions)
Yes, auditory privacy (A room where others are not likely to hear conversations)
Yes, both visual and auditory privacy
No privacy
E19
Does Adolescent Friendly Health Clinic have following signs/ documents?
E19_1
The signboard of the clinic at a prominent place with the logo of RKSK?
Yes
No
E19_2
Is AFHC service a part of Citizen Charter of the facility?
Yes
No
E19_3
Are there SRH educational materials, posters or job aids on site which are designed to provide information to adolescents? (Based on observation)
Yes
No
E19_4
What issues related to sexual and reproductive health of adolescents does IEC material capture?
Family planning
Teen pregnancy
Abortion care
Post-abortion care
RTI/STI
HIV infection
E20
Does Adolescent Friendly Health Clinic have following furniture?
E20_1
3 Chairs
Yes
No
E20_2
1 Table
Yes
No
E20_3
Curtains on doors and windows - As per need
Yes
No
E20_4
1 Bedside Screen
Yes
No
E20_5
1 Examination Table
Yes
No
E20_6
1 Almirah
Yes
No
E20_7
1 Step Tool
Yes
No
E20_8
Bench / Chair for waiting area As per need
Yes
No
E21
Does Adolescent Friendly Health Clinic have following Equipment and instruments?
E21_1
Weighing Machine
Yes
No
E21_2
BP Apparatus
Yes
No
E21_3
Stethoscope
Yes
No
E21_4
Thermometer
Yes
No
E21_5
Measuring Tape
Yes
No
E21_6
Torch / Flashlight
Yes
No
E21_7
Snellen’s Chart
Yes
No
E21_8
Height Chart
Yes
No
E22
Does Adolescent Friendly Health Clinic have following commodities?
E22_1
IFA tablets
Yes
No
E22_2
Albendazole tablets
Yes
No
E22_3
Sanitary napkin
Yes
No
E22_4
Contraceptives condoms
Yes
No
E22_5
OCP
Yes
No
E22_6
Chhaya
Yes
No
E22_7
Emergency contraceptive pills
Yes
No
E22_8
Pregnancy testing kits
Yes
No
E22_9
Other medicines (Paracetamol, anti-spasmodic and first aid)
Yes
No
E23
Are following registers available at AFHC?
E23_1
Client registration register
Yes
No
E23_2
Service Provision Register
Yes
No
E23_3
Stock Register
Yes
No
E23_4
Outreach Sessions Register
Yes
No
E23_5
Does this Adolescent Friendly Health Clinic send consolidated report to districts?
Yes
No
AVAILABILITY OF SWASTHYA SAMWAAD KENDRA
F01
Name of the respondent
F02
Designation of the respondent
Medical Superintendent, Hospital
Superintendent
Hospital Manager
Medical Officer in Charge of the Hospital
Other best - informed person (specify)
F03
Phone number of the respondent
F04
Is this facility in mandate of government to have SSK?
Yes
No
F05
Do you wish to have SSK in this facility?
Yes
No
F06
Does this facility provide any services as mandated under Swasthya Samwaad Kendra?
Yes
No
F07
Is there a separate cell/ place/infrastructure for RKSK Adolescent Friendly Health Centre and Swasthya Samwaad kendra?
Yes, separate cell for SSK
No, there is a combined place/cell for AFHC/ RKSK and SSK
F08
Does Swasthya Samwaad Kendra have the following staff?
F08_1
Counsellors
Yes
No
F08_2
If yes, how many (total)?
F08_3
Staff nurses (during opening hours) at sample collection area
Yes
No
F08_4
Data entry operator
Yes
No
F08_5
Fourth grade staff
Yes
No
F08_6
Is there a site signage of Swasthya Samwaad Kendra?
Yes
No
F09
Is there a separate area for Swasthya Samwaad services?
Yes
No
F10
Is there a waiting area near Swasthya Samwaad Kendra?
Yes
No
F11
Does waiting area have following
F11_1
Drinking water facility
Yes
No
F11_2
Minimum of 5 seating benches
Yes
No
F11_3
Television with security box
Yes
No
F11_4
Video clips of 2-3 minutes displayed on television
Yes
No
F12
Is there a group counselling area in Swasthya Samwaad Kendra?
Yes
No
F13
Does group counselling area have following?
F13_1
Dimension of the room – 15 *12 feet or 10*15 feet
Yes
No
F13_2
Audio visual privacy (if there is a partition then it should be up to ceiling)
Yes, audio privacy
Yes, visual privacy
Both
No privacy
F13_3
5-6 seating benches
Yes
No
F13_4
1 table and 1 chair for counsellor
Yes
No
F13_5
Space to display IEC material
Yes
No
F13_6
Condoms
Yes
No
F13_7
Mala N
Yes
No
F13_8
IUCD
Yes
No
F13_9
Model to display condom use
Yes
No
F14
Total number of counselling room in Swasthya Samwaad Kendra
F14A
Audio privacy
F14A_1
Room 1
Yes
No
F14A_2
Room 2
Yes
No
F14A_3
Room 3
Yes
No
F14B
Visual privacy
F14B_1
Room 1
Yes
No
F14B_2
Room 2
Yes
No
F14B_3
Room 3
Yes
No
F14C
Table and chair for counsellor
F14C_1
Room 1
Yes
No
F14C_2
Room 2
Yes
No
F14C_3
Room 3
Yes
No
F14D
3 chairs for patients
F14D_1
Room 1
Yes
No
F14D_2
Room 2
Yes
No
F14D_3
Room 3
Yes
No
F15
Has facility displayed the available service in Swasthya Samwaad Kendra?
Yes
No
F16
Are working hours displayed at prominent place outside Swasthya Samwaad Kendra?
Yes
No
F17
What are the working hours of Swasthya Samwaad Kendra?
F18
Does Swasthya Samwaad Kendra have computer, laptops, tablets for digital data entry
Yes
No
F19
Doe Swasthya Samwaad Kendra have internet connection?
Yes
No
F20
Is there any Register in SSK?
Yes
No
SUPPLY CHAIN OF FAMILY PLANNING AND ABORTION COMMODITIES.
G01
Name of the respondent
G02
Designation of the respondent
Medical Superintendent, Hospital
Superintendent
Hospital Manager
Medical Officer in Charge of the Hospital
Other best - informed person (specify)
G03
Phone number of the respondent
G04
Who is the principal person responsible for managing the ordering of medical supplies at this facility?
Staff nurse
Medical officer/ civil surgeon/ block medical officer
Pharmacist
Don’t Know
Other
G05
Which of the following mechanisms is used to determine this facility’s resupply quantities?
G05A
The facility itself (pull distribution system)
Yes
No
G05B
A higher-level facility (push distribution system)
Yes
No
G06
How are the facility’s resupply quantities determined?
Based on previous procurement pattern
Based on experienced demand
Based on available stock at warehouse/ higher facility
Don’t know
Other means (specify?)
G07
What is the main source of your FP commodity supplies? By this I mean who is the direct supplier to your facility?
Government medical stores
Ngo/donors
Private sources
Local vendor
Other (specify)
G08
What is the main source of your abortion drugs i.e. Misoprostol, mifepristone supplies? By this I mean who is the direct supplier to your facility?
Government medical stores
Ngo/donors
Private sources
Empaneled local vendor by Bhopal corporation
Other (specify)
G09
What is the main source of MVA kit supplies in your facility? By this I mean who is the direct supplier of MVA to your facility?
IPAS
Government medical stores
Ngo/donors
Private sources
Empaneled local vendor by Bhopal corporation
Other (specify)
G10
Who is responsible for transporting products from central medical stores to your facility?
Local supplier delivers
Higher level delivers
This facility collects
Other
G11
For the most recent order to abortion commodities/ MVA, how long did it take between ordering and receiving products?
Less than 2 weeks
2 weeks to 1 month
Between 1 and 2 months
More than 2 months
G12
For the most recent order related to FP commodities how long did it take between ordering and receiving products?
Less than 2 weeks
2 weeks to 1 month
Between 1 and 2 months
More than 2 months
G13
Is there a dedicated person trained to enter data in the system?
G13_1
FPLMIS
Yes
No
G13_2
E-Aushadhi
Yes
No
G13_3
HMIS
Yes
No
G13_4
EMMS
Yes
No
G14
Who is that person?
G14_1
FPLMIS
Data entry operator
Pharmacist
Counsellor
Other specify
G14_2
E-Aushadhi
Data entry operator
Pharmacist
Counsellor
Other specify
G14_3
HMIS
Data entry operator
Pharmacist
Counsellor
Other specify
G14_4
EMMS
Data entry operator
Pharmacist
Counsellor
Other specify
G15
When was it last logged in?
G15_1
FPLMIS
Last week
In last 15 days
In last 30 days
G15_2
E-Aushadhi
Last week
In last 15 days
In last 30 days
G15_3
HMIS
Last week
In last 15 days
In last 30 days
G15_4
EMMS
Last week
In last 15 days
In last 30 days
G16
How frequently is the data entry done?
G16_1
FPLMIS
In realtime
Every day
Every week
Every 2 weeks
Every month
No fixed periodicity
G16_2
E-Aushadhi
In realtime
Every day
Every week
Every 2 weeks
Every month
No fixed periodicity
G16_3
HMIS
In realtime
Every day
Every week
Every 2 weeks
Every month
No fixed periodicity
G16_4
EMMS
In realtime
Every day
Every week
Every 2 weeks
Every month
No fixed periodicity
G17
Are there any software related problems faced by the operator?
G17_1
FPLMIS
Yes
No
G17_2
E-Aushadhi
Yes
No
G17_3
HMIS
Yes
No
G17_4
EMMS
Yes
No
G18
If yes, how frequently do they face those?
G18_1
FPLMIS
Every day
Once in a week
Once in 15 days
Once in a month
G18_2
E-Aushadhi
Every day
Once in a week
Once in 15 days
Once in a month
G18_3
HMIS
Every day
Once in a week
Once in 15 days
Once in a month
G18_4
EMMS
Every day
Once in a week
Once in 15 days
Once in a month
G19
FINISH TIME
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