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Process Checklist Template -Form Fill

INFORMATION
Q01

Name of District
Q02

District Code
Q03

Name of Block
Q04

Block Code
Q05

Name of Village

Q06

Village Code

Q07

Name of ASHA

Q08

Name of Baby

Q09

Name of Mother

Q10

Name of Father

Q11

Place of Delivery
Q12

Type of Delivery

Q13

Date of Delivery

Q14

Date of discharge

Q15

Date of Observation

Q16

How many Days old
Q17

Name of Observer
General Observations
A01

Did the ASHA ever visit the child before this visit?
A02

If yes, on which day(s) of life was the child visited by the ASHA?

A02_1

Day - 1
A02_2

Day - 3
A02_3

Day - 7
A02_4

Day - 14
A02_5

Day - 21
A02_6

Day - 28
A02_7

Day - 42
General Observations 2
B01

Does the AHSA have ASHA Drug Kit?
B02

Are the following items available in her drug kit?

B02_1

DDK for Clean deliveries at home
B02_2

Tab. Paracetamol
B02_3

Paracetamol syrup
B02_4

Tab. Iron Folic Acid (L)
B02_5

Tab. Punarvadu Mandur (ISM Preparation of Iron)
B02_6

Tab. Dicyclomine
B02_7

Tetracycline ointment
B02_8

Zinc Tablets
B02_9

Povidine Ointment Tube
B02_10

G.V. Paint
B02_11

Cotrimoxazole syrup
B02_12

Paediatric Cotrimoxazole tablets
B02_13

ORS Packets
B02_14

Condoms
B02_15

Oral pills (In cycles)
B02_16

Spirit
B02_17

Soap
B02_18

Sterilized Cotton
B02_19

Bandages, 4cm X 4 meters
B02_20

Nischay Kit
B02_21

Rapid Diagnostic Kit
B02_22

Slides for Malaria & Lancets
B02_23

Emergency Contraceptive Pill
B02_24

Sanitary napkins
General Observations 3
B03

Are the following equipment available?

B03_1

Digital Wrist Watch
B03_2

Thermometer
B03_3

Weighing Scale (for newborn)
B03_4

Sling of the weighing scale

B03_5

Baby Blanket
B03_6

Baby Feeding spoon
B03_7

Mucous Extractor
Examination of the baby
C01

Is the Baby Alive?
C02

Did she check whether the eyes of baby are Swollen or with Pus?
C03

If the eyes are with pus, did she apply antibiotic ointment?
C04

What else did the ASHA do?
C05

Did she measure the weight of the baby?
C06

If yes, then what is the weight (in Kgs)?
C07

If baby is < 1.8 Kgs, did she refer the baby to SNCU?
C08

What else did the ASHA do?
C09

Did she measure & record the temperature?
C10

If yes, what is the temperature (in degree F)?
C11

If temperature is > 99 degree F, did she look for signs of sepsis?
C12

If sepsis not present, did she manage with 1/4 th spoon of paracetamol and immediately refer to SNCU?
C13

What else did the ASHA do?
C14

Did she check for presence of jaundice (yellowness in eyes or skin)?
C15

Did ASHA ask/verify the mother regarding whether the baby has received the BCG ?
C16

Did she ask/verify whether the baby has received the OPV ?
C17

Did she ask/verify whether the baby has received the Hep B (0)?
Examination of mother
D01

Is the mother alive?
D02

Did ASHA measure & record the temperature of Mother?

D03

What was the temperature?
D04

If temperature is > 102 degree F, did ASHA refer the mother to hospital?
D05

What else did the ASHA do?
D06

Did ASHA ask/verify mother for foul smelling discharge and fever (> 100 degree F)?
D07

If the woman had foul smelling discharge, did ASHA refer mother to hospital?
D08

What else did the ASHA do?
D09

Did ASHA check whether mother is speaking abnormally or having fits?
D10

If the woman was speaking abnormally or had fits, did ASHA refer mother to hospital?
D11

What else did the ASHA do?
D12

Did ASHA check for excessive bleeding?
D13

In case of excessive bleeding, did ASHA refer mother to hospital?
D14

What else did the ASHA do?
D15

Did ASHA ask/verify mother whether she has no milk since delivery or if perceives breast milk to be less?
D16

If the woman reported such a problem, did ASHA counsel the mother and ask her to feed the baby more often?
D17

What else did the ASHA do?
D18

Did ASHA check whether mother has engorged breast/ cracked nipple?
D19

If the woman had such a problem, did ASHA advice mother to feed the baby frequently?

D20

Did ASHA advice the woman to express her milk herself?

D21

What else did the ASHA do?
D22

Did ASHA Counsel the mother for adoption of an appropriate family planning method?

D23

Did ASHA build confidence and skills of mother to safeguard her health and that of new-born?

HBNC Checklist
E01

Does the ASHA have the HBNC checklist with her?
E02

Did the ASHA fill Form 1-A (Visit details) of the HBNC checklist?
E03

Did the ASHA fill Form 1-B (child health) of the HBNC checklist?

E04

Did the ASHA fill Form 1-C (mother’s health) of the HBNC checklist?

Comments
F01

Please comment on understanding of ASHA regarding the HBNC Visit.

F02

Please comment on the preparedness of ASHA for the HBNC visit

F03

Please comment on the support provided by CRP/ASHA Sangini to ASHA during HBNC Visit
F04

Please comment on the quality of counselling given to the mother on postpartum care, recognition of postpartum complications by ASHA
F05

Please comment on the quality of counselling given to the mother for adoption of appropriate family planning method by ASHA