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Follow up Health Facility Template -Form Fill
FACILITY IDENTIFIERS
Q01
Date
Q02
District
Q03
Block
Q04
Facility Name
Q05
Village Name
Q06
Cluster number
Q07
Facility Type
PHC
CHC
Govt Hospital
Private Facility
Other
Q08
Facility Ownership
Government
Mission
Private
Q09
GPS Longitude
Q10
GPS Latitude
Q11
Interviewer Initials
EQUIPMENT, DRUGS AND VACCINES
A01
Does the facility have the following essential support services?
A01_1
Source of clean running water (eg bucket+plug; piped water)
Yes
No
A01_2
Electricity connection
Yes
No
A01_3
Electricity supply at time of interview
Yes
No
A01_4
Does the facility have an alternative power supply
Yes
No
A01_5
Functional sterilizer, cooker or stove
Yes
No
A01_6
Functional fridge
Yes
No
A01_7
Toilets accessible to facility users
Yes
No
A01_8
Motorised transport for referral
Yes
No
A01_9
How many cars/ambulances are available?
A01_10
Is there a vehicle for referral in the facility now?
Yes
No
A01_11
The last time there was an obstetric referral out of the facility which transport was used?
facility owned vehicle
district office owned vehicle
she used her own vehicle
public transport
non-motorised vehicle
don’t know
A01_12
Which means of communication do you have to speak to another facility?
Facility landline/mobile phone
Staff member mobile phone
Phone outside the facility
Radio
No means of communication
A01_13
The last time a woman was referred to another facility for treatment did you speak to the facility directly?
Yes
No
A01_14
If yes, Which means of communication did you use?
Facility landline/mobile phone
Staff member mobile phone
Phone outside the facility
Radio
A01_15
The last time a woman was referred to another facility for maternity care did a staff member accompany her?
Yes
No
A01_16
If yes: Which cadre of staff member accompanied her?
Nurse
ANM/Midwife
Doctor
Other
A01_17
Is there a newborn care corner in this facility?
Yes
No
A01_18
Does this facility use the Better Birth check list?
Yes
No
A02
Does the facility have the following equipment and materials today?
A02_1
Accessible and working baby scale
Yes
No
A02_2
Vaccination cards
Yes
No
A02_3
Fetoscope
Yes
No
A02_4
Stethoscope
Yes
No
A02_5
Blood pressure machine (sphygmomanometer)
Yes
No
A02_6
Single use needles and syringes for vaccinations
Yes
No
A02_7
Suture material with needles
Yes
No
A02_8
Needle holder
Yes
No
A02_9
Sterile scissors or blade
Yes
No
A02_10
Sharps boxes
Yes
No
A02_11
Soap
Yes
No
A02_12
Accessible and working adult scale
Yes
No
A02_13
Working watch or timing device
Yes
No
A02_14
Antenatal cards
Yes
No
A02_15
Supplies to mix ORS, cups and spoons
Yes
No
A02_16
Height stick
Yes
No
A02_17
Disposable gloves
Yes
No
A02_18
Single-use hand drying towels
Yes
No
A02_19
Waste receptacle with lid and plastic liner
Yes
No
A02_20
Disinfectant
Yes
No
A02_21
Room giving visual privacy
Yes
No
A02_22
24- hour functioning light source
Yes
No
A02_23
Thermometer
Yes
No
A02_24
Intravenous fluids with infusion set
Yes
No
A02_25
Manual vacuum aspirator for abortion care
Yes
No
A02_26
Speculum
Yes
No
A02_27
Aspiration kit
Yes
No
A02_28
Oxygen
Yes
No
A02_29
Blank partograph
Yes
No
A02_30
Vacuum extractor (for vacuum delivery/assisted delivery)
Yes
No
A02_31
Newborn suction device
Yes
No
A02_32
Newborn resuscitationBag and mask Size 0
Yes
No
A02_33
Newborn resuscitationBag and mask Size 1
Yes
No
A02_34
Mucus trap/suction machine
Yes
No
A02_35
Clamp or umbilical tie
Yes
No
A02_36
Gentian violet paint
Yes
No
A02_37
Dextrose saline/ORS
Yes
No
A02_38
Utensils for breastmilk expression and cup feeding
Yes
No
A02_39
Nasogastric tubes/20ml syringes
Yes
No
A02_40
Binders for Kangaroo Mother Care
Yes
No
A02_41
Blanket to wrap newborn
Yes
No
A02_42
Towel to dry the newborn at birth
Yes
No
A02_43
Baby warmer/heat lamp
Yes
No
A02_44
Phototherapy
Yes
No
A02_45
What numbers of rooms are there at the facility?
A02_46
What number of beds available in the maternity area?
A02_47
What method is available to assess gestation weeks of a pregnancy in this facility?
A02_47A
Ultrasound
Yes
No
A02_47B
Fundal height/physical examination
Yes
No
A02_47C
Menstrual calendar
Yes
No
A03
Does the facility have the following drugs available today?
A03_1
Sulphadoxine Pyrimethamine for IPT
Yes
No
A03_2
Vitamin A
Yes
No
A03_3
Ferrous Sulphate
Yes
No
A03_4
Folic Acid
Yes
No
A03_5
Combined ferrous/folate
Yes
No
A03_6
Benzyl penicillin
Yes
No
A03_7
Diazepam (IM or IV)
Yes
No
A03_8
Mebendazol
Yes
No
A03_9
Amoxicillin
Yes
No
A03_10
Oral Penicilin or ampicilin
Yes
No
A03_11
Cefotaxime/Aminoglycoside
Yes
No
A03_12
Calcium gluconate
Yes
No
A03_13
Cotrimoxizole
Yes
No
A03_14
Tetracycline ointment or silver nitrate eye drops
Yes
No
A03_15
Corticosteroids (for preterm labour)
Yes
No
A03_16
Ergometrine (oral or injectable)
Yes
No
A03_17
Oxytocin
Yes
No
A03_18
Misoprostol
Yes
No
A03_19
IV Penicilin
Yes
No
A03_20
IV Ampicillin
Yes
No
A03_21
IV Gentamycin
Yes
No
A03_22
IV Metronidazole
Yes
No
A03_23
Local anaesthetics (such as lidocaine)
Yes
No
A03_24
Zinc tablets
Yes
No
A03_25
Nevirapine (or Tenofovir (TDF) or Lamivudine (3TC) or Efavirenz (EFV)
Yes
No
A03_26
Chlorhexidine
Yes
No
A04
Does the facility have the following vaccines in stock today?
A04_1
TT vaccine
Yes
No
A04_2
Vitamin K
Yes
No
A04_3
BCG
Yes
No
A04_4
OPV
Yes
No
A05
Which of the following test kits are available in this clinic today?
A05_1
Pregnancy test kit
Yes
No
A05_2
Proteinuria
Yes
No
A05_3
Rapid test for malaria
Yes
No
A05_4
Does the facility offer HIV diagnostics in this clinic?
Yes
No
A05_5
If yes: Does the facility have HIV rapid tests in stock today?
Yes
No
A05_6
Does the facility offer syphilis diagnosis?
Yes
No
A05_7
If yes: Does the facility have syphilis RPR syphilis tests in stock today?
Yes
No
A05_8
Does the facility have syphilis rapid tests in stock today?
Yes
No
A05_9
Does the facility have anaemia tests in stock today?
Yes
No
FACILITY SERVICES
B01
How many days per week is the facility open?
B02
What services are routinely offered at this clinic?
B03
Antenatal registration and counselling
Yes
No
B04
If yes: are antenatal services available today?
Yes
No
B05
If yes: what is the cost of a routine antenatal consultation?
B06
Vaccination
Yes
No
B07
If yes: are vaccination services available today?
Yes
No
B08
If yes: what is the cost of vaccination services for pregnant women?
B09
PMTCT
Yes
No
B10
If yes: are PMTCT services available today?
Yes
No
B11
Family planning counselling
Yes
No
B12
If yes: is family planning counselling available today?
Yes
No
B13
If yes: what is the cost of routine family planning counselling?
B14
Post-natal health checks for mother and newborn
Yes
No
B15
If yes: are PNC available today?
Yes
No
B16
If yes: what is the cost of routine post-natal health checks?
B17
Maternity/Intra-partum/Delivery care
Yes
No
B18
If yes: is maternity/delivery care available today?
Yes
No
B19
If maternity/deliver services are offered: How many days per week are maternity/delivery services available?
B20
If maternity/delivery services are offered: How many days per week are maternity/delivery services available 24 hours/day?
B21
If yes: what is the cost of routine maternity/delivery care?
B22
Abortion services
Yes
No
B23
If yes: are abortion services available today?
Yes
No
B24
If yes: what is the cost of routine abortion services?
B25
Are there ever any meetings where service statistics are discussed with staff working at this facility?
Yes
No
B26
Does the facility practise Kangaroo Mother Care (KMC)?
Yes
No
B27
Health staff on the day of survey
B27A
Doctors
B27A_1
Employed in the facility?
B27A_2
Ever trained in clean and safe delivery?
B27A_3
Ever trained in essential newborn care/PNC?
B27A_4
Ever trained in PMTCT?
B27A_5
Ever trained in syphilis screening?
B27A_6
Ever trained to use the Better Birth Checklist?
B27A_7
Provide antenatal care?
B27A_8
Attend deliveries?
B27A_9
Provide essential newborn care?
B27A_10
At work today?
B27B
Staff nurse
B27B_1
Employed in the facility?
B27B_2
Ever trained in clean and safe delivery?
B27B_3
Ever trained in essential newborn care/PNC?
B27B_4
Ever trained in PMTCT?
B27B_5
Ever trained in syphilis screening?
B27B_6
Ever trained to use the Better Birth Checklist?
B27B_7
Provide antenatal care?
B27B_8
Attend deliveries?
B27B_9
Provide essential newborn care?
B27B_10
At work today?
B27C_1
ANM/Midwife
B27C_2
Employed in the facility?
B27C_3
Ever trained in clean and safe delivery?
B27C_4
Ever trained in essential newborn care/PNC?
B27C_5
Ever trained in PMTCT?
B27C_6
Ever trained in syphilis screening?
B27C_7
Ever trained to use the Better Birth Checklist?
B27C_8
Provide antenatal care?
B27C_9
Attend deliveries?
B27C_10
Provide essential newborn care?
B27C_11
At work today?
B27D_1
Support staff (patient care)
B27D_2
Employed in the facility?
B27D_3
Ever trained in clean and safe delivery?
B27D_4
Ever trained in essential newborn care/PNC?
B27D_5
Ever trained in PMTCT?
B27D_6
Ever trained in syphilis screening?
B27D_7
Ever trained to use the Better Birth Checklist?
B27D_8
Provide antenatal care?
B27D_9
Attend deliveries?
B27D_10
Provide essential newborn care?
B27D_11
At work today?
B27E
Total
B27E_1
Employed in the facility?
B27E_2
Ever trained in clean and safe delivery?
B27E_3
Ever trained in essential newborn care/PNC?
B27E_4
Ever trained in PMTCT?
B27E_5
Ever trained in syphilis screening?
B27E_6
Ever trained to use the Better Birth Checklist?
B27E_7
Provide antenatal care?
B27E_8
Attend deliveries?
B27E_9
Provide essential newborn care?
B27E_10
At work today?
B28
Did the facility receive supervision in the last six months?
Yes
No
B29
When was the last supervision visit to this facility?
B30
Which supervisors came on the last visit?
B30_1
Government health team
Yes
No
B30_2
Other Medical doctor
Yes
No
B30_3
Project visitor
Yes
No
B30_4
Vaccine official
Yes
No
B31
Which of the following are
B31_1
Use of partograph
routine practise during deliveries in this clinic
not practised in this clinic
B31_2
Active management of 3rd stage of labour (AMTSL)
routine practise during deliveries in this clinic
not practised in this clinic
B31_3
Newborn stays with mother in the same room
routine practise during deliveries in this clinic
not practised in this clinic
B31_4
Mother receives vitamin A before discharge
routine practise during deliveries in this clinic
not practised in this clinic
B31_5
Newborns are weighed immediately after birth
routine practise during deliveries in this clinic
not practised in this clinic
B31_6
Newborns are fully bathed within 24 hours of birth
routine practise during deliveries in this clinic
not practised in this clinic
B31_7
Newborn given OPV vaccine prior to discharge
routine practise during deliveries in this clinic
not practised in this clinic
B31_8
Newborn given BCG vaccine prior to discharge
routine practise during deliveries in this clinic
not practised in this clinic
B31_9
Newborn given vitamin K prior to discharge
routine practise during deliveries in this clinic
not practised in this clinic
B31_10
Newborn cord applied chlorhexidine
routine practise during deliveries in this clinic
not practised in this clinic
FACILITY RECORDS
C01
During the last six months
C01_1
What was the total number of deliveries in the clinic?
C01_2
What was the number of normal deliveries in the clinic?
C01_3
What was the number of caesarean sections in the clinic?
C01_4
What was the number of maternal fatalities in the clinic?
C01_5
What was the number of live births in the clinic?
C01_6
What was the number of still births in the clinic?
C01_7
Have you heard about five minute APGAR score?
Yes
No
C01_8
Do you record that in the register/notebook?
Yes
No
C01_9
What was the number of live births with an five minute APGAR score of
C01_10
Number with no APGAR score recorded
C01_11
What was the number of live births with birth weight <2500 grammes (or <2.5kg)?
C01_12
How many live birth records did not have birth weight recorded?
C01_13
What was the number of live births recorded as preterm births?
C01_14
What was the number of live births with no gestational age recorded?
C01_15
What numbers of newborns were referred out of the facility for treatment/extra care?
C01_16
What numbers of newborns were admitted in this facility for treatment/extra care?
C01_17
Are the maternity record books completely up to date until the day before survey?
Yes
No
C01_18
What is the date of the most recent birth recorded in the maternity register?
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