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Doctor Template -Form Fill

Identification
Q01

Serial number
Q02

District name
Q03

District code
Q04

Block name
Q05

Block code
Q06

Health Facility name
Q07

Health Facility code
Q08

Type of Health Facility
Q09

Level of Health Facility
Q10

Date of interview (DD/MM/YYYY)
Q11

Start time of interview

Q12

End time of interview
Q13

Name of the interviewer
Q14

Name of the supervisor
Q15

Interview Result:
Background Information
A01

Name of the Respondent
A02

Age of the Respondent
A03

Current designation at the facility
A04

Please indicate your highest qualification
A05

How long have you been working as a health provider after formal completion of your education?
A06

How long have you worked in the facility where you are currently posted?
A07

Which type of family planning services do you personally provide?
A08

If no, can you tell us the reason for not providing family planning services?
A09

Which abortion services do you personally provide at this facility?
A10

If no, can you tell us the reason for not providing abortion services?
A11

Do you personally provide post-abortion care services which includes counselling on post abortion FP, danger signs, side-effects to patients and treatment or referral for complications?
A12

If no, can you tell us the reason for not providing post abortion care services?
A13

Do you provide sexual and reproductive health services/counselling to adolescents of 10-17 years age?
A14

Which of the sexual and reproductive health services/counselling do you provide to adolescents from 10-17 years?
A15

If no, can you tell us the reason for not providing sexual and reproductive health services/counselling to adolescents of age 10-17 years?
Abortion and post abortion care
B01

According to MTP Act, no one other than a specialist with post-graduate degree or diploma in gynaecology and obstetrics can carry out termination of pregnancy
B02

Second trimester abortions can be done at which types of government health facilities?

B03

Under what conditions/indications, can a pregnancy be terminated as per the MTP law?
B04

Consent of a guardian is required to terminate pregnancy in what case?
B05

As per MTP law, for pregnancy up to how many weeks opinion of one RMP is required for performing the MTP procedure?
B06

Under the MTP Act amendments 2002, MTP can be performed up to 24 weeks of pregnancy with the opinion of two doctors
B07

No documentation is required in cases done with Medical Methods of Abortion since it does not involve a surgical procedure
B08

What documentation needs to be done/forms need to be filled in an abortion case?
B09

Which method of the contraception should NOT be provided immediately following second trimester abortion
Adolescent friendly health services
C01

Providing information on sexuality and safe sex to adolescents will do more harm than good -True or False
C02

If safe abortion services are made available and accessible to adolescents, it will encourage promiscuity.
C03

Nightfall in boys is
C04

Which temporary methods of contraception should be avoided in adolescent girls less than 17 years of age?
Counselling skills assessment
D01

Ruksana, 18 years old and Salim, 21 years old are a just-married couple with no children. They do not want children for another 2 years as Salim has just started working and cannot support a child. They visit the nearby sub-centre for consultation on family planning. The busy ANM asks them to enter consultation room and quickly take their seat. She notes down their names in the register and asks them the purpose of their visit. Ruksana and Salim share their concern about not wanting a child so soon. But as their family was against contraception, they were not sure what to do. Interrupting Ruksana at this point, the ANM tells them she has seen many such cases from their community. Thinking that the couple would not adhere to any method regularly, the ANM told them they should use IUCD method for contraception. She told them that Ruksana should come on Tuesday to get the IUCD inserted at the PHC . The ANM handed them a pamphlet on IUCD and told them to read it before coming on Tuesday. The ANM called out for the next client.
D01A

The ANM was respectful in her behaviour towards Ruksana and Salim
D01B

The ANM was non-judgemental towards Ruksana and Salim and their situation.
D01C

The ANM suggested the right method for the couple as per their needs.
D01D

The ANM provided appropriate information to Ruksana and Salim.
D01E

The ANM provided appropriate referral for contraception to the young couple.
D02

During an OPD session, Kavita, a 16-year-old unmarried girl comes with her mother for a check-up at the hospital. She has been keeping unwell for a few weeks with occasional bouts of vomiting, especially in the morning. She seems to be the youngest among all the patients waiting there. The lady doctor calls Kavita and her mother into consultation room and greets them. After taking history from Kavita, the doctor does an abdominal check-up in a private area while her mother waits outside. While doing the examination, Kavita tells her that she also has missed her periods. The doctor becomes suspicious that Kavita may be pregnant. The angry doctor asks Kavita to tell the truth as she thinks that she is 12 weeks pregnant. Scared Kavita reveals that she has a boyfriend and he had forced her to have sex a few times. The doctor scolds her that she should have concentrated on studying instead of having a relationship.

D02A

The doctor reacted appropriately to Kavita’s situation.
D02B

The doctor was non-judgemental towards Kavita and her situation.
D02C

The doctor gave Kavita the right legal information regarding abortion.
D02D

The doctor gave all the relevant information to Kavita regarding abortion.
D02E

The doctor provided appropriate referral advice to Kavita.
D02F

Should the doctor take opinion of another RMP for decision on termination of Kavita’s pregnancy?
D02G

What methods of contraception should the doctor suggest to Kavita?
D03

Shardadevi, 21-years-old, is a mother of a 15 -month old boy. She recently found out that she was 12 weeks pregnant again. Already having a difficult previous pregnancy, she goes for an abortion to nearby CHC. For surgical abortion procedure, her husband takes a day off work to be present on the insistence of hospital staff to bring a guardian. After her surgical abortion procedure, the nurse comes at her bedside for post-abortion care counselling. The nurse who was going off-duty in half an hour, quickly told Shardadevi about self-care for following few days and danger signs for which she should immediately report to the health centre. While repeatedly glancing at watch and ignoring her husband, the nurse asked Shardadevi what method of contraceptive she wants to adopt. Shardadevi told her she was not sure as she had never used any method of contraception.

D03A

The nurse was respectful towards Shardadevi and her situation.
D03B

The nurse was non-judgemental towards Sharda’s situation while giving post-abortion care counselling.
D03C

The nurse suggested the right kind of family planning method considering Shardadevi’s needs.
D03D

The nurse gave all the relevant information regarding family planning methods to Shardadevi.
D03E

The nurse followed all the steps of appropriate counselling for Shardadevi’s counselling session.
Training in family planning, abortion services and adolescent friendly health services
E01

Non-scalpel vasectomy (NSV)
E01A

Did you ever receive this training?
E01B

If not received, do you want this training?
E01C

Did you receive this training in last 12 months?
E01D

What were the topics covered in the training? (last 12 months)
E01E

Did you find this training useful? (last 12 months)
E02

PPIUCD insertion training
E02A

Did you ever receive this training?
E02B

If not received, do you want this training?
E02C

Did you receive this training in last 12 months?
E02D

What were the topics covered in the training? (last 12 months)
E02E

Did you find this training useful? (last 12 months)
E03

IUCD insertion training
E03A

Did you ever receive this training?
E03B

If not received, do you want this training?
E03C

Did you receive this training in last 12 months?
E03D

What were the topics covered in the training? (last 12 months)
E03E

Did you find this training useful? (last 12 months)
E04

Injectable Contraceptive DMPA (Antara)
E04A

Did you ever receive this training?
E04B

If not received, do you want this training?
E04C

Did you receive this training in last 12 months?
E04D

What were the topics covered in the training? (last 12 months)
E04E

Did you find this training useful? (last 12 months)
E05

Centchromen (Chhaya)
E05A

Did you ever receive this training?
E05B

If not received, do you want this training?
E06

Oral Contraceptive Pills
E06A

Did you ever receive this training?
E06B

If not received, do you want this training?
E07

Emergency Contraceptive Pills
E07A

Did you ever receive this training?
E07B

If not received, do you want this training?
E08

Family planning counselling
E08A

Did you ever receive this training?
E08B

If not received, do you want this training?
E08C

Did you receive this training in last 12 months?
E08D

What were the topics covered in the training? (last 12 months)
E08E

Did you find this training useful? (last 12 months)
E09

Comprehensive Abortion care
E09A

Did you ever receive this training?
E09B

If not received, do you want this training?
E09C

Did you receive this training in last 12 months?
E09D

What were the topics covered in the training? (last 12 months)
E09E

Did you find this training useful? (last 12 months)
E10

Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic)
E10A

Did you ever receive this training?
E10B

If not received, do you want this training?
E10C

Did you receive this training in last 12 months?
E10D

What were the topics covered in the training? (last 12 months)
E10E

Did you find this training useful? (last 12 months)
E11

Following your training related to MVA and / or MMA, were you assigned a mentor?
E12

In the year following your training, how many times did you connect with your mentor over the phone?
E13

In the year following your training, how many times did your mentor visit your facility?
Male engagement for family planning
F01

According to you, who currently makes FP decisions in the household?
F02

Out of clients approaching you for FP services, In your experience , what percentage of males are willing / open to accept condoms?

F03

Out of the clients that come to you for FP services, In your experience of providing FP services, what percentage of males are willing / open to accept NSVs?
F04

What are the challenges faced by you in talking to men regarding family planning?
F05

Do you need any extra training to be able to talk to men about family planning?
Workflow in abortion cases
G01

Have you ever seen a case of under 18 married teen pregnancy that may be unwanted?
G02

If yes, what do you do in such cases?
G03

Have you ever seen a case of under 18 unmarried teen pregnancy that may be unwanted?
G04

If yes, what do you do in such cases?
G05

Have you ever seen a case of unmarried pregnant woman above 18 years of age seeking abortion?
G06

If yes, what do you do in such cases?
G07

What is the documentation you will follow for under 18 abortion cases?