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Anm & Asha Vhnd Observation -Form Fill

VILLAGE LOCATION
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
Q13

NAME OF ASHA
Q14

ASHA CODE
INTERVIEWER VISITS
A01

DATE OF VISIT
A02

INTERVIEWER NAME
A03

INTERVIEWER ID
A04

RESULT CODES
A05

START TIME
Basic background information on the VHND organisation, preparedness and planning
B01

Please describe the site of VHND
B02

When did the ANM reach VHND site? Record the exact time.
B03

What efforts were made to ensure participation of all beneficiaries listed in the due list?
B04

Were the families of the beneficiaries identified as resistant or hard to reach and were offers made to bring them to VHND?
B05

What efforts were made to bring the drop-out women / children to the VHND?
General Observations
C01

When was the last VHND conducted in the village?
C02

Are VHNDs conducted regularly in the village?
C03

Was the micro plan made for the current VHND?
C04

Is this the regular place for conducting the VHND as per the micro plan?
C05

Was ASHA present during VHND?
C06

Was AWW present during VHND?
C07

Is there any external person present in the VHND apart from the ASHA, ANM or the AWW?
C08

Who was present in the VHND?
C09

Is the due list of beneficiaries available with the ANM?
C10

Is the due list of beneficiaries available with ASHA?
C11

Is the due list of beneficiaries available with AWW?
C12

Who was maintaining the records during the VHND?
Room readiness
D01

Is there a banner about VHND at the site?
D02

Is there provision for clean drinking water?
D03

Are blank MCH card available?
D04

Are referral slips available?
Logistics
E01

Are the following equipment available at the VHND site?
E01_1

Weighing scale (adult)
E01_2

Weighing scale (child)
E01_3

Examination table
E01_4

Bed screen / Curtain
E01_5

Stethoscope
E01_6

Blood Pressure instrument
E01_7

Measuring tape
E01_8

Measuring tape for MUAC
E01_9

Foetoscope
E01_10

Haemoglobin meter
E01_11

Urine examination kit
E01_12

Gloves
E01_13

Slides
E01_14

Hub cutter
E01_15

IEC material
E01_16

Waste disposal
Supplies
F01

Are the following supplies available at the VHND site?
F01A

Vaccines
F01A_1

TT
F01A_2

BCG
F01A_3

OPV
F01A_4

DPT
F01A_5

HB-V
F01A_6

JE
F01A_7

Measles
F01B

Dilutant for the following
F01B_1

BCG
F01B_2

DPT
F01B_3

Measles
F01C

Paracetamol
F01D

Albendazole
F01E

IFA tablets (adult)
F01F

IFA tablets (paediatric)
F01G

Vitamin A
F01H

Anti TB drugs
F01I

ORS
F01J

Zinc
F01K

Condoms
F01L

OCP
F01M

ECP
Services: Maternal Health
G01

Are the following activities being done
G01_1

Registration of pregnancies
G01_2

Height measurement
G01_3

Weight measurement
G01_4

BP measurement
G01_5

Abdominal examination
G01_6

Haemoglobin testing
G01_7

Administration of TT injection
G01_8

Distribution of IFA tablets
G01_9

Referral for women with complications during pregnancy
G01_10

Referral for safe abortion
G01_11

Care during pregnancy
G01_12

Danger signs during pregnancy
G01_13

Birth preparedness
G01_14

Importance of nutrition
G01_15

Institutional delivery
G01_16

Identification of referral transport
G01_17

JSY funds
Services: Child Health and Nutrition
H01

Were the following activities done
H01_1

Registration of new births
H01_2

Routine immunization
H01_3

First dose of Vitamin A along with measles vaccine
H01_4

Weight measurement
H01_5

Counselling for care of New born and feeding
H01_6

Distribution of IFA tablets to children with Anaemia
H01_7

Weight measurement
H01_8

Recording weight in growth monitoring charts
H01_9

Booster dose of DPT/OPV
H01_10

Second to fifth dose of Vitamin A
H01_11

Identification of children as malnourished
H01_12

Referral for severely malnourished children
H01_13

Distribution of supplementary nutrition
H01_14

Case management of children suffering from diarrhoea
H01_15

Case management of children suffering from ARI
Counselling
I01

Counselling to mothers on home management of diseases
I02

Counselling on and management of worm infestation
Services: Reproductive Health
J01

Were the following activities done
J01_1

Distribution of contraceptives
J01_2

Counselling on use of contraceptives
J01_3

Counselling on prevention and treatment of RTIs and STIs including HIV/AIDS
WORK LOAD ON VHND
L01

Number of beneficiaries that attended the VHND
L02

Number of beneficiaries who availed counselling (including adolescent, pregnant mothers, post natal care of mother and early childhood care)
L03

Number of eligible women who received TT injection
L04

Number of eligible women who received IFA tablets
L05

No. of beneficiaries who availed Child Healthcare Services
L06

No. of beneficiaries who availed Family Planning Services
L07

No. of beneficiaries who availed treatment for RTI/STI
L08

No. of beneficiaries who availed treatment for Communicable diseases
L09

No. of beneficiaries who availed education on health promotion
L10

No. of beneficiaries who availed education on nutrition
Observation of the whole day activities on VHND
M01

Please comment on the quality of counselling to the beneficiaries.
M02

comment on the behaviour of the FLWs towards the beneficiaries during the VHND.
M03

How service delivery at VHND can be improved? Ask each FLW
M03A

ASHA
M03B

AWW
M03C

ANM
M04

Any other observations?
M05

Note interview End time