Surveypoint

Q01

District Name

Q02

District Code

Q03

Block Name

Q04

Block Code

Q05

Facility Name

Q06

Facility Code

Q07

Facility Type

L1

L2

L3

Q08

Block Type

TSU

NHM

Non-TSU

NHPD

Q09

Date of observation

Q10

Name of observer

A01

Name of mother

A02

Date of admission

A03

Name of Father

A04

Phone Number

A05

Name of Village

A06

Nearest Landmark

A07

Name of block

A08

Name of District

A09

ASHA Name

A10

ASHA phone number

A11

Was the woman referred before delivery

Yes

No

A12

Child Name

A13

Gender

Male

Female

A14

Date of birth

A15

Weight Recorded

Yes

No

A16

Weight (in grams)

B01

Was it a maternal complication?

Yes

No

B02

What was the type of complication?

PROLONGED LABOR

OBSTRUCTED LABOR

RUPTURE OF MEMBRANE > 12 HOURS WITHOUT LABOR

RUPTURE OF MEMBRANE>18 HOURS IN LABOUR

PREGNANCY INDUCED HYPERTENSION

MILD/SEVERE PRE-ECLAMPSIA

ECLAMPSIA

ANTEPARTUM HEMORRAGE

INFECTION / SEPSIS

PRE-TERM LABOR

PREMATURE RUPTURE OF MEMBRANES

POST PARTUM HEMORRAGE

OTHERS (SPECIFY)

B03

Was the complication managed at the facility?

Yes

No

B04

How was the complication managed?

B05

What was the outcome of the complication?

MANAGED AND SENT HOME HEALTHY

MANAGED AND REFERRED

MANAGED, REFERRED AND SURVIVED

MANAGED, REFERRED AND DIED

MANAGED, REFERRED AND STATUS NOT KNOWN

DIED AT FACILITY

OUTCOME NOT KNOWN

OTHER (SPECIFY)

B06

Was it a new-born complication?

Yes

No

B07

What was the type of complication?

PRETERM BIRTH (<37 WEEKS GESTATION)

LOW BIRTH WEIGHT (<2500 GRAMS)

ASPHYXIA (NOT BREATHING AFTER 30 SECONDS BAG AND MASK)

INFECTION / SEPSIS

BIRTH ANOMALIES

OTHERS (SPECIFY)

B08

Was the complication managed at the facility?

Yes

No

B09

How was the complication managed?

B10

What was the outcome of the complication?

MANAGED AND SENT HOME HEALTHY

MANAGED AND REFERRED

MANAGED, REFERRED AND SURVIVED

MANAGED, REFERRED AND DIED

MANAGED, REFERRED AND STATUS NOT KNOWN

DIED AT FACILITY

OUTCOME NOT KNOWN

OTHER (SPECIFY)

C01

Was follow-up done?

Yes

No

C02

Date of follow-up

C03

Status of mother and child

Mother and child both are alive

Mother is alive but child is dead

Child is alive but mother is dead

Complications Tracking Template -Form Fill

District Name

District Code

Block Name

Block Code

Facility Name

Facility Code

Facility Type

Block Type

Date of observation

Name of observer

Name of mother

Date of admission

Name of Father

Phone Number

Name of Village

Nearest Landmark

Name of block

Name of District

ASHA Name

ASHA phone number

Was the woman referred before delivery

Child Name

Gender

Date of birth

Weight Recorded

Weight (in grams)

Was it a maternal complication?

What was the type of complication?

Was the complication managed at the facility?

How was the complication managed?

What was the outcome of the complication?

Was it a new-born complication?

What was the type of complication?

Was the complication managed at the facility?

How was the complication managed?

What was the outcome of the complication?

Was follow-up done?

Date of follow-up

Status of mother and child